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AHIMA Certified Documentation Integrity Practitioner Sample Questions:

1. Yes/No queries may be used

A) when the diagnosis is not clearly documented in the health record
B) in any query format
C) when only the clinical indicators of a condition are present
D) to resolve conflicting documentation from multiple practitioners

2. An 80-year-old male is admitted as an inpatient to the ICU with shortness of breath, productive yellow sputum, and a temperature of 101.2. CXR reveals bilateral pleural effusion and LLL pneumonia. Labs reveal a BUN of 42 and a creatinine level of 1.500.
The patient is given Zithromax 500 mg. IV, NS IV, and Lasix 40 mg tabs 2x/day. The attending physician documents bilateral pleural effusion, LLL pneumonia, and kidney failure. Two days later, the renal consult documents AKI with acute tubular necrosis (ATN). The correct principal and secondary diagnoses are

A) PDx: Bilateral pleural effusion
SDx: LLL pneumonia, kidney failure
B) PDx: AKI with ATN
SDx: LLL pneumonia, bilateral pleural effusion
C) PDx: LLL pneumonia
SDx: Bilateral pleural effusion, kidney failure
D) PDx: LLL pneumonia
SDx: AKI with ATN, bilateral pleural effusion

3. A 75-year-old, diabetic patient with a history of osteoporosis, being treated with Fosamax, who sustained a femur fracture after falling down three stairs. The provider's documentation indicates to admit the patient for a traumatic femur fracture and an orthopedics consult is pending. The clinical documentation integrity practitioner (CDIP) decides to query for a possible link between osteoporosis and the femur fracture. Which of the following is the most compliant query based on the most recent AHIMA/ACDIS query practice brief?

A) Patient admitted for a femur fracture with a history of osteoporosis being treated with Fosamax. Please clarify the cause of the femur fracture in your next note and/or the discharge summary.
B) Patient admitted for a femur fracture with a history of osteoporosis being treated with Fosamax. Please document "femur fracture due to osteoporosis" in your next progress note to demonstrate a link between the two diagnoses.
C) Patient admitted for a femur fracture with a history of osteoporosis being treated with Fosamax. Could diabetes be a contributing factor in the femur fracture?
D) Patient admitted for a femur fracture with a history of osteoporosis being treated with Fosamax. In your medical opinion, is this fracture consistent with an osteoporotic pathological fracture?

4. The clinical documentation integrity (CDI) manager is reviewing physician benchmarks and notices a low-severity level being measured against average length of stay.
What should the CDI manager keep in mind when discussing this observation with physicians?

A) The query response rate directly correlates to quality reports.
B) The query rate is too high while the agreement rate is low.
C) The diagnosis with a higher degree of specificity has a lower severity of illness.
D) The indicator is a key factor of measurement for quality reports.

5. A query should be generated when documentation contains a

A) problem list with symptoms related to the chief complaint
B) postoperative hospital-acquired condition
C) principal diagnosis without an MCC
D) diagnosis without clinical validation

Solutions: