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AHIMA Certified Documentation Integrity Practitioner Sample Questions:

1. Which entity has the following regulation?
A medical history and physical examination be completed and documented for each patient no more than 30 days before or 24 hours after admission or registration, but prior to surgery or a procedure requiring anesthesia services.

A) Office of the National Coordinator for Health Information Technology
B) Office of Inspector General
C) Centers for Medicare & Medicaid Services
D) Office for Civil Rights

2. Which of the following should an organization consider when developing a query retention policy and procedure?

A) What the escalation process will be
B) If the query is considered part of the health record
C) How the query will be formatted
D) Who should be queried

3. A hospital clinical documentation integrity (CDI) director suspects physicians are over-using electronic copy and paste in patient records, a practice that increases the risk of fraudulent insurance billings. A documentation integrity project may be needed. What is the first step the CDI director should take?

A) Alert senior leadership to the record documentation problem
B) Bring together a team of physicians and informatics specialists
C) Gather data on the incidence of inaccurate record documentation
D) Recommend the physicians to be involved in the project

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

5. When benchmarking with outside organizations, the clinical documentation integrity practitioner (CDIP) must determine if the organization is benchmarking with which of the following criteria?

A) Hospital within its county
B) Hospital within its region
C) Hospital within its state
D) Hospitals that are its peers

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