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AHIMA CDIP Exam Syllabus Topics:

AHIMA Certified Documentation Integrity Practitioner Sample Questions:

1. Which factors are important to include when refocusing the primary vision of a clinical documentation integrity (CDI) program?

A) Benchmarks and case mix index
B) Reporting and the use of technology
C) Diagnostic related groups and revenue cycle
D) Value and mission statements

2. When a change in departmental workflow is necessary, the first step is to

A) define the gaps and solutions
B) set realistic timelines
C) assess the current workflow
D) re-engineer the process

3. Which physician would best benefit from additional education for unanswered queries?

A) Dr. C
B) Dr. D
C) Dr. A
D) Dr. B

4. A patient was admitted due to possible pneumonia. Chest x-ray was positive for infiltrate. The physician's documentation indicates that the patient continues to smoke cigarettes despite recommendations to quit. Patient also has a long-term history of chronic obstructive pulmonary disease (COPD) due to smoking. IV antibiotic was given for pneumonia along with oral Prednisone and Albuterol for COPD.
Discharge diagnoses:
1. Pneumonia
2. COPD
3. Current smoker
What is the correct diagnostic related group assignment?

A) DRG 190 Chronic Obstructive Pulmonary Disease with MCC
B) DRG 202 Bronchitis and Asthma with CC/MCC
C) DRG 204 Respiratory Signs and Symptoms
D) DRG 194 Simple Pneumonia and Pleurisy without CC/MCC

5. A 100-year-old female presents to the emergency department with altered mental state and a 3-day history of productive cough, shortness of breath, and fever after a witnessed aspiration 3 days ago. The patient lives in custodial care at a nearby skilled nursing facility. Patient was treated with Augmentin at the facility without improvement. Exam is notable for Tc 38.9, blood pressure 142/78, respiratory rate 28, pulse 91. There is accessory muscle use with breathing.
Patient is moaning and disoriented but
otherwise the neurologic exam is nonfocal.
Labs notable for sodium 126, creatinine 0.5. white blood count 17.5, hemoglobin 13, platelet 200. venous blood gas 7.44/32/45/-3 Chest x-ray shows bilateral lower lobe infiltrates and dense right lower lobe consolidation.
Patient is placed on bilevel positive airway pressure and given vancomycin, pip/tazo, levofloxacin.
Discharge Diagnosis: health care associated pneumonia (HCAP), respiratory distress, altered mental status, low sodium Which list of diagnoses require a post-discharge query that will result in a more specific principal diagnosis with the highest level of severity of illness and risk of mortality?

A) Severe sepsis, hypernatremia, delirium, pneumonia
B) Sepsis with acute hypoxemic respiratory failure, hyponatremia, pneumonia
C) Aspiration pneumonia, hyponatremia, septic encephalopathy, and sepsis with acute hypoxemic respiratory failure
D) Coma, stroke, HCAP, hypernatremia

Solutions: