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AHIMA CDIP Exam Syllabus Topics:

AHIMA Certified Documentation Integrity Practitioner Sample Questions:

1. For inpatients with a discharge principal diagnosis of acute myocardial infarction, aspirin must be taken within
24 hours of arrival unless a contraindication to aspirin is
documented. How should this be documented in the health record?

A) The name of the medication (aspirin), the date and time it was last administered
B) The name of the medication (aspirin), the date, time and location where it was last administered
C) The name of the medication (aspirin) and the date it was last administered
D) The name of the medication (aspirin), the date and location where it was last administered

2. A query should be generated when the documentation is

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

3. Which of the following is considered a hospital-acquired condition if not present on admission?

A) Blood incompatibility
B) Stage I and II pressure ulcers
C) Diabetes with hypoglycemia
D) Air leak

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. A patient is admitted for chronic obstructive pulmonary disease (COPD) exacerbation. The patient is on 3L of home oxygen and is treated during admission with 3L of oxygen. The most appropriate action is to

A) query the provider to see if respiratory insufficiency is supported by the health record
B) query the provider to see if acute on chronic respiratory failure is supported by the health record
C) code the diagnoses of COPD exacerbation and chronic respiratory failure
D) query the provider to see if chronic respiratory failure is supported by the health record

Solutions: