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AHIMA CDIP Exam Syllabus Topics:

AHIMA Certified Documentation Integrity Practitioner Sample Questions:

1. A 94-year-old female patient is admitted with altered mental status and inability to move the left side of her body. She is diagnosed with a cerebral vascular accident with left sided weakness. The patient is ambidextrous, but the physician does not specify the predominance of the affected side. The default code is

A) non-dominant
B) ambidextrous
C) dominant
D) preferred

2. Identify the error in the following query:
This patient's echocardiogram showed an ejection fraction of 25%. The chest x-ray showed congestive heart failure (CHF). The patient was prescribed Lasix and an angiotensin-converting enzyme inhibitor (ACEI). Is this patient's CHF systolic?

A) The query is unclear.
B) The query is leading.
C) The query does not contain clinical indicators.
D) The query contains irrelevant information.

3. After one year, the clinical documentation integrity (CDI) program has become stagnant, and the manager plans to reinvigorate the program to better reflect the CDI efforts in the organization. What can the manager do to ensure program success?

A) Expand the CDI program to larger areas in outpatient clinics
B) Prioritize to focus on efforts with the largest return on investment
C) Identify key metrics to develop program measures for coders
D) Establish a CDI steering committee to build a strong foundation

4. Hospital policy states that physician responses to queries should be no longer than timely payer filing requirements. A physician responds to a query after the final bill has been submitted. How should administration respond in this situation?

A) Maintain the original billing as supported by documentation in the medical record
B) Review the record to determine any potential data integrity impact and/or rebilling implications
C) Evaluate the payer's timeframe for billing and reasons for the physician's delayed response
D) Report the physician's delayed response to the Ethics and Compliance Committee

5. Which of the following criteria for clinical documentation means the content of the record is trustworthy, safe, and yielding the same result when repeated?

A) Reliable
B) Legible
C) Complete
D) Precise

Solutions: