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AHIMA Certified Documentation Integrity Practitioner Sample Questions:

1. The clinical documentation integrity (CDI) manager is reviewing physician benchmarks and notices a low-severity level being measured against average length of stay.
What should the CDI manager keep in mind when discussing this observation with physicians?

A) The query rate is too high while the agreement rate is low.
B) The diagnosis with a higher degree of specificity has a lower severity of illness.
C) The query response rate directly correlates to quality reports.
D) The indicator is a key factor of measurement for quality reports.

2. A 70-year-old severely malnourished nursing home patient is admitted for a pressure ulcer covered by eschar on the right hip. The provider is queried to clarify the stage of the pressure ulcer. Because the wound has not been debrided, the provider responds "unable to determine".
How will the stage of this pressure ulcer be coded?

A) Unstageable pressure ulcer
B) Stage IV pressure ulcer
C) Undetermined stage pressure ulcer
D) Stage III pressure ulcer

3. Based on the flowchart below, at what point might the clinical documentation integrity practitioner (CDIP) enlist the help of the physician advisor/champion?

A) C - Retrospective query opportunity identified
B) H - Physician fails to respond tocquery
C) E - Physician agrees with query and documents in MR
D) D - No retrospective query opportunity identified

4. A resident returns to the long-term care facility following hospital care for pneumonia. The physician's orders and progress note state "Continue IV antibiotics for pneumonia - 3 more days, after which time the resident is to have a repeat x-ray to determine status of the pneumonia". Is it appropriate to code the pneumonia in this scenario?

A) Yes, J18.9, Pneumonia, unspecified organism, should be coded until the condition is resolved
B) No, since the patient needed a repeat x-ray, the condition does not clarify as a diagnosis
C) Yes, J18.9, Pneumonia, unspecified organism, Z79.2 should be coded along with long term antibiotics
D) Yes J18.8, Pneumonia, other specified organism

5. A physician documented the specific site of the malignancy in the medical record documentation; however, the coder is unable to locate a specific entry in the ICD-10- CM Alphabetical Index to match the specified diagnosis. Which abbreviation used in the Alphabetical Index will assist the coder in assigning the appropriate diagnosis code for the specified condition?

A) NOS
B) DRG
C) NEC
D) OCE

Solutions: