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AHIMA Certified Documentation Integrity Practitioner Sample Questions:

1. Which of the following is MOST likely to trigger a second-level review?

A) An account coded before the discharge summary is available
B) A procedure code that increases reimbursement
C) A diagnosis that impacts a quality-of-care measure
D) A record with multiple major complicating conditions (MCCs)

2. A patient is admitted due to pneumonia. On day 1, a sputum culture is positive for psuedomonas bacteria. If the physician is queried and agrees that the patient has pseudomonas pneumonia, this specificity would

A) meet medical necessity
B) not increase relative weight
C) not meet medical necessity
D) increase relative weight

3. A clinical documentation integrity practitioner (CDIP) generates a concurrent query and continues to follow retrospectively; however, the coder releases the bill before the query is answered. The CDIP wonders if it is appropriate to re-bill the account if the physician answers the query after the bill has dropped. Which policy should the hospital follow to avoid a compliance risk?

A) A post bill query is not appropriate when an error is found after an audit.
B) A second bill should not be submitted when the first bill was incomplete.
C) A post-bill query rarely occurs as a result of an audit or other internal monitor.
D) A rebilling is permissible when queries are answered after the initial bill.

4. The clinical documentation integrity practitioner (CDIP) performed a verbal query and then later neglected following up with the provider. How should the CDIP avoid a compliance risk for this follow up failure according to AHIMA's Guidelines for Achieving a Compliant Query Practice?

A) Complete the documentation at the end of the day when entering cases reviewed
B) Complete the documentation immediately after the provider's response
C) Complete the documentation when there is a provider agreement
D) Complete the documentation at the time of discussion or immediately following

5. Which of the following is an appropriate first step to address physicians with low query response rates?

A) An educational session between the clinical documentation integrity practitioner (CDIP) and physician
B) The medical staff review the physician's noncompliance to consider sanctions
C) A meeting between the physician advisor/champion and the noncompliant physician
D) The physician receives a suspension until query responses are improved

Solutions: