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AHIMA CDIP Exam Syllabus Topics:

AHIMA Certified Documentation Integrity Practitioner Sample Questions:

1. A patient presents to the emergency room with complaint of cough with thick yellow/greenish sputum, and generalized pain. Admitting vital signs are noted below and sputum culture performed. The patient is admitted with septicemia due to pneumonia and has received 2L of normal saline and piperacillin/ tazobactam. After all results were reviewed, on day 2, the hospitalist continued to document septicemia due to pneumonia.
White blood count BC 18,000
Temperature 101.5
Heart rate 110
Respiratory rate 24
Blood pressure 95/67
Sputum culture (+) klebsiella pneumoniae
Which diagnosis implies that a query was sent and answered?

A) Septicemia due to klebsiella pneumoniae
B) Severe sepsis with pneumonia due to klebsiella pneumoniae
C) Sepsis with pneumonia due to klebsiella pneumoniae
D) Sepsis with respiratory failure due to pneumonia

2. A hospital clinical documentation integrity (CDI) director suspects physicians are over-using electronic copy and paste in patient records, a practice that increases the risk of fraudulent insurance billings. A documentation integrity project may be needed. What is the first step the CDI director should take?

A) Gather data on the incidence of inaccurate record documentation
B) Bring together a team of physicians and informatics specialists
C) Alert senior leadership to the record documentation problem
D) Recommend the physicians to be involved in the project

3. The correct coding for insertion of a dialysis catheter into the right internal jugular vein with the tip ending in the cavoatrial junction is

A) 05HP33Z Insertion of infusion device into right external jugular vein, percutaneous approach
B) 02HV33Z Insertion of infusion device into superior vena cava, percutaneous approach
C) 02H633Z Insertion of infusion device into right atrium, percutaneous approach
D) 05HM33Z Insertion of infusion device into right internal jugular vein, percutaneous approach

4. Which of the following is a clinical documentation element supporting a transbronchial biopsy?

A) Pathology report documenting alveolar tissue
B) Pathology report documenting bronchial tissue
C) Length of procedure
D) Hemoptysis

5. Besides the physician advisor/champion, who should be included as a key stakeholder in the clinical documentation integrity (CDI) steering committee to promote CDI initiatives?

A) Manager of Surgical Services
B) Director of Informatics
C) Director of Risk Management
D) Manager of HIM/Coding

Solutions: