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AHIMA CDIP Exam Syllabus Topics:

AHIMA Certified Documentation Integrity Practitioner Sample Questions:

Question 1

A patient has a history of asthma and presents with complaints of fever, cough, general body aches, and lethargy. The patient's child was recently diagnosed with influenza. Wheezing is heard on exam. The physician documents the diagnosis as asthma exacerbation and orders nebulizer treatments of Albuterol and a 5-day course of oral Prednisone. The clinical documentation integrity practitioner (CDIP) is unsure which signs and symptoms are inherent to asthma. Which reference resource should be used to obtain this information?

A. Medical Dictionary
B. Physician's Desk Reference
C. The Merck Manual
D. AMA CPT Assistant

Question 2

The key component of the auditing and monitoring process to ensure provider query response is to

A. make sure that the language in the query is not leading or otherwise inappropriate
B. review queries retrospectively to ensure that they are completed according to documented Policies and procedures
C. audit individual providers to indicate improvement in health record documentation
D. have a process in place for ongoing education and training of the staff involved in conducting provider queries

Question 3

Which of the following individuals is the first line of escalation for an unanswered query?

A. CDI Steering Committee
B. CDI Manager
C. Medical Director
D. HIM/Coding Manager

Question 4

A patient's progress note states "The patient has chronic systolic heart failure". After reviewing clinical indicators suggestive of an exacerbation of systolic heart failure, the clinical documentation integrity practitioner (CDIP) queries the physician to clarify the current acuity of the diagnosis. Which subsequent documentation in the health record suggests the provider did not understand the query?

A. The patient has chronic systolic heart failure.
B. The patient did have an exacerbation of heart failure.
C. The patient has decompensated systolic heart failure.
D. The patient has acute on chronic systolic heart failure.

Question 5

A query should be generated when the documentation is

A. complete
B. conflicting
C. consistent
D. legible

Solutions: