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AHIMA Certified Documentation Integrity Practitioner Sample Questions:

1. The physician advisor/champion needs to provide ongoing education regarding coding and reimbursement regulations to the

A) organization's medical and surgical staff
B) Health Information Management coding staff
C) organization senior administration staff
D) clinical documentation integrity staff

2. A resident returns to the long-term care facility following hospital care for pneumonia. The physician's orders and progress note state "Continue IV antibiotics for pneumonia - 3 more days, after which time the resident is to have a repeat x-ray to determine status of the pneumonia". Is it appropriate to code the pneumonia in this scenario?

A) No, since the patient needed a repeat x-ray, the condition does not clarify as a diagnosis
B) Yes J18.8, Pneumonia, other specified organism
C) Yes, J18.9, Pneumonia, unspecified organism, Z79.2 should be coded along with long term antibiotics
D) Yes, J18.9, Pneumonia, unspecified organism, should be coded until the condition is resolved

3. 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) Value and mission statements
C) Diagnostic related groups and revenue cycle
D) Reporting and the use of technology

4. What type of query may NOT be used in circumstances where only clinical indicators of a condition are present, and the condition/diagnosis has not been documented in the health record?

A) Verbal
B) Yes/No
C) Open-ended
D) Multiple-choice

5. Which of the following is the definition of an Excludes 2 note in ICD-10-CM?

A) This is not a convention found in ICD-10-CM
B) Only one code can be assigned to completely describe the condition
C) Neither of the codes can be assigned
D) Two codes can be used together to completely describe the condition

Solutions: