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AHIMA CDIP Exam Syllabus Topics:

AHIMA Certified Documentation Integrity Practitioner Sample Questions:

1. The clinical documentation integrity practitioner (CDIP) is reviewing tracking data and has noted physician responses are not captured in the medical chart. What can be done to improve this process?

A) Allow physician responses via e-mail
B) Provide education to physicians on query process
C) Require the CDIP to call physicians to follow up
D) Update medical records with unsigned physician responses

2. A 50-year-old male patient was admitted with complaint of 3-day history of shortness of breath. Vital signs:
BP 165/90, P 90, T 99.9.F, O2 sat 95% on room air. Patient
has history of asthma, chronic obstructive pulmonary disease (COPD), and hypertension (HTN). His medicines are Albuterol and Norvasc. CXR showed chronic lung disease and left lower lobe infiltrate. Labs: WBC 9.5 with 65% segs. Physician documented that patient has asthma flair and admitted with decompensated COPD, ordered IV steroids, O2 at 2L/min via nasal cannula, Albuterol inhalers 4x per day, and Clindamycin. Patient improved and was discharged 3 days later. Which action would have the highest impact on the patient's severity of illness (SOI) and risk of mortality (ROM)?

A) Query the physician to clarify for clinical significance of the CXR results.
B) Query the physician to clarify if patient has acute COPD exacerbation.
C) Query the physician to clarify if CXR result means patient has pneumonia.
D) Query the physician to clarify for type of COPD such as severe asthma.

3. Which of the following individuals should the clinical documentation integrity (CDI) manager consult when developing query policy and procedures?

A) Compliance Officer
B) Chief Medical Officer
C) Chief Financial Officer
D) CDI practitioner

4. Which of the following organizations should a clinical documentation integrity practitioner (CDIP) monitor?

A) Recovery Auditors (RAs), Program for Evaluating Payment Patterns Electronic Report (PEPPER), Office of Inspector General (OIG)
B) Center for Improvement in Healthcare (CIHQ), Accreditation Commission for Healthcare (ACHC), Recovery Auditors (RAs)
C) Program for Evaluating Payment Patterns Electronic Report (PEPPER), Recovery Auditors (RAs), Center for Improvement in Healthcare (CIHQ)
D) Office of Inspector General (OIG), Accreditation Commission for Healthcare (ACHC), Recovery Auditors (RAs)

5. What policies should query professionals follow?

A) CMS's policies related to querying
B) All healthcare entity's policies are the same
C) Their healthcare entity's internal policies related to querying
D) AHIMA's policies related to querying

Solutions: