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AHIMA CDIP Exam Syllabus Topics:

AHIMA Certified Documentation Integrity Practitioner Sample Questions:

Question 1

Which of the following is used to measure the impact of a clinical documentation integrity (CDI) program on Centers for Medicare and Medicaid Services quality performance?

A. Severity of illness
B. Case mix index
C. Risk of mortality
D. Outcome measures

Question 2

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

Question 3

A patient presents to the emergency room with acute shortness of breath. The patient has a history of lung cancer that has been treated previously with radiation and chemotherapy. The patient is intubated and placed on mechanical ventilation. A chest x-ray is remarkable for a pleural effusion. A thoracentesis is performed, and the cytology results show malignant cells. Diagnoses on discharge: Acute respiratory failure due to recurrence of small cell carcinoma and malignant pleural effusion. Which coding reference takes precedence for assigning the ICD-10-CM/PCS codes?

A. Conventions and instructions of the classification for ICD-10-CM/PCS
B. AHA Coding Clinic for ICD-10-CM/PCS
C. ICD-10-CM Official Guidelines for Coding and Reporting
D. AMA CPT Assistant

Question 4

A patient presents to the emergency department for evaluation after suffering a head injury during a fall. A traumatic subdural hematoma is found on MRI, and the patient is taken directly to the operating room for evacuation. The neurosurgeon performs a burr hole procedure for evacuation of the subdural hematoma. The clot is removed successfully, and the patient is transferred to recovery in stable condition. Which is the correct current procedural terminology (CPT) code assignment for the procedure performed?

A. 61140 Burr hole(s) or trephine; with biopsy of brain or intracranial lesion
B. 61108 Twist drill hole(s) for subdural, intracerebral, or ventricular puncture; for evacuation and/or drainage of subdural hematoma
C. 61154 Burr hole(s) with evacuation and/or drainage of hematoma, extradural or subdural
D. 61105 Twist drill hole subdural/ventricular puncture

Question 5

The correct coding for heart failure with preserved ejection fraction is

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

Solutions: