AHIMA CDIP

Propositional trend analysis is accurate

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Universal answer template

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AHIMA CDIP Exam Syllabus Topics:

AHIMA Certified Documentation Integrity Practitioner Sample Questions:

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

2. A clinical documentation integrity practitioner (CDIP) is reviewing an outpatient surgical chart. The patient underwent a laparoscopic appendectomy for acute gangrenous appendicitis. Which coding reference should be used for coding advice on correct assignment of the procedure code for proper ambulatory payment classification (APC) reimbursement?

A) O ICD-10-CM/PCS Codebook
B) The Merck Manual
C) O AMA CPT Assistant
D) AHA Coding Clinic for ICD-10-CM/PCS

3. Yes/No queries may be used

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

4. A patient receives a blood transfusion after a 400 ml blood loss during surgery. The clinical documentation integrity practitioner (CDIP) queries the physician for an associated diagnosis. The facility does not maintain queries as part of the permanent health record. What does the physician need to document for the CDIP to record the query as answered and agreed?

A) The associated diagnosis and the clinical rationale in the progress notes
B) That the blood loss was not clinically significant
C) The associated diagnosis directly on the query form
D) A cause-and-effect relationship between anemia and the underlying cause

5. A patient presented with shortness of breath, elevated B-type natriuretic peptide, and lower extremity edema to the emergency room. During the hospitalization, a cardiac echocardiogram was performed and revealed an ejection fraction of 55% with diastolic dysfunction. The patient's history includes hypertension (HTN), chronic kidney disease (CKD) (baseline glomerular filtration rate 40) and congestive heart failure (CHF). The clinical documentation integrity practitioner (CDIP) has queried the physician to further clarify the patient's diagnosis. Which response provides the highest level of specificity?

A) Acute CHF with hypertensive renal disease, CKD 3
B) Acute diastolic CHF with HTN and CKD 3
C) Acute on chronic diastolic CHF with hypertensive renal disease, CKD 3
D) Acute on chronic systolic CHF with hypertensive renal disease, CKD 3

Solutions: