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AHIMA CDIP Exam Syllabus Topics:

AHIMA Certified Documentation Integrity Practitioner Sample Questions:

1. Which of the following is MOST likely to trigger a second-level review?

A) A diagnosis that impacts a quality-of-care measure
B) An account coded before the discharge summary is available
C) A procedure code that increases reimbursement
D) A record with multiple major complicating conditions (MCCs)

2. Review the following query to determine if it is compliant:
Dr. Jones, this patient had a sodium level of 126 on admission and was started on a 0.9% saline IV. Can you indicate what condition is being treated?
Dehydration
Hyponatremia
Hypernatremia
Chronic kidney disease (indicate stage)
Other (please specify)

A) No, query is noncompliant as it does not provide the option of "unable to determine".
B) Yes, query is compliant as it offers the minimum number of multiple-choice answers ..
C) No, query is noncompliant as one of the multiple-choice options is clinically irrelevant.
D) Yes, query is compliant as it provides clinical indicators and several options for response.

3. Which of the following should be shared to ensure a clear sense of what clinical documentation integrity (CDI) is and the CDI practitioner's role within the organization?

A) Mission
B) Milestones
C) Productivity standards
D) Review schedule

4. The correct coding for heart failure with preserved ejection fraction is

A) I50.20 Unspecified systolic (congestive) heart failure
B) I50.30 Unspecified diastolic (congestive) heart failure
C) 150.32 Chronic diastolic (congestive) heart failure
D) I50.9 Heart failure, unspecified

5. A 45-year-old female is admitted after sustaining a femur fracture. Orthopedics is consulted and performs an open reduction internal fixation (ORIF) of the femur without complication. Nursing documents the patient has a body mass index of 42 kg/m2. The clinical documentation integrity practitioner (CDIP) determines a query is needed to capture a diagnosis associated with the body mass index so it can be reported. Which of the following is the MOST compliant query based on the most recent AHIIMA/ACDIS query practice brief?

A) Nursing documents the BMI is 42 kg/m2. In order to capture a co-morbid condition (CC) to increase reimbursement, please add 'morbid obesity with BMI 42 kg/m2' to your next progress note.
B) Nursing documents the BMI is 42 kg/m2. Can you please clarify if the patient's morbid obesity was present on admission and add the diagnosis to future progress notes?
C) Nursing documents the BMI is 42 kg/m2. To increase the severity of illness and risk of mortality, please add 'morbid obesity with BMI 42 kg/m2' to your next progress note.
D) Nursing documents the BMI is 42 kg/m2. Please consider if any of the following diagnoses should be added to the health record to support this finding: morbid obesity; obesity; other diagnosis (please state)

Solutions: