Printable format of the PDF version

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We can promise 365 days free updates

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AHIMA Certified Documentation Integrity Practitioner Sample Questions:

1. A patient presents to the emergency room with complaint of cough with thick yellow/greenish sputum, and generalized pain. Admitting vital signs are noted below and sputum culture performed. The patient is admitted with septicemia due to pneumonia and has received 2L of normal saline and piperacillin/ tazobactam. After all results were reviewed, on day 2, the hospitalist continued to document septicemia due to pneumonia.
White blood count BC 18,000
Temperature 101.5
Heart rate 110
Respiratory rate 24
Blood pressure 95/67
Sputum culture (+) klebsiella pneumoniae
Which diagnosis implies that a query was sent and answered?

A) Severe sepsis with pneumonia due to klebsiella pneumoniae
B) Sepsis with pneumonia due to klebsiella pneumoniae
C) Sepsis with respiratory failure due to pneumonia
D) Septicemia due to klebsiella pneumoniae

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

3. Which of the following should be examined when developing documentation integrity projects?

A) Query rates from coding staff
B) CC and MCC capture rates
C) Coding productivity statistics
D) Physician satisfaction surveys

4. When a change in departmental workflow is necessary, the first step is to

A) set realistic timelines
B) assess the current workflow
C) re-engineer the process
D) define the gaps and solutions

5. Which factors are important to include when refocusing the primary vision of a clinical documentation integrity (CDI) program?

A) Value and mission statements
B) Benchmarks and case mix index
C) Diagnostic related groups and revenue cycle
D) Reporting and the use of technology

Solutions: