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AHIMA CDIP Exam Syllabus Topics:

AHIMA Certified Documentation Integrity Practitioner Sample Questions:

1. An 88-year-old male is admitted with a fever, cough, and leukocytosis. The physician documents admit for probable sepsis due to urinary tract infection (UTI). Antibiotics are started. Three days later, the blood and urine cultures are negative, the patient has been afebrile since admission, and the white blood count is returning to normal. What documentation clarification is needed to support accurate coding of the record?

A) Send a clinical validation query for both the diagnoses of sepsis and UTI.
B) Send a clinical validation query for only the diagnosis of sepsis.
C) A clinical validation query is not required for either diagnosis.
D) Send a clinical validation query for only the diagnosis of UTI.

2. The best approach in resolving unanswered queries is to

A) notify the physician advisor/champion that the physician has not responded to the query
B) notify the coding team of the physician's unanswered query
C) review the facility's query policies and procedures
D) contact the physician repeatedly until he/she responds to the query

3. A clinical documentation integrity practitioner (CDIP) hired by an internal medicine clinic is creating policies governing written queries. What is an AHIMA best practice for these policies?

A) Queries for illegible chart notes are unnecessary
B) Primary care physicians must answer written queries
C) Queries are limited to non-leading questions
D) Non-responses to written queries are grounds for discipline

4. Which of the following is a clinical documentation element supporting a transbronchial biopsy?

A) Pathology report documenting bronchial tissue
B) Pathology report documenting alveolar tissue
C) Hemoptysis
D) Length of procedure

5. A pressure ulcer stage III is documented in the progress note. The clinical documentation integrity practitioner (CDIP) has queried the attending regarding the present on admission status of the pressure ulcer but has not received a response in an appropriate time frame. What should the CDIP do next?

A) Escalate issue to medical staff leadership
B) Query surgical consultant
C) Escalate issue to hospital administration
D) Query wound care nurse

Solutions: