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AHIMA Certified Documentation Integrity Practitioner Sample Questions:

1. What is the term used when a patient is entered in the Master Patient Index (MPI) multiple times, in different ways, resulting in multiple medical record numbers?

A) Facsimile
B) Replica
C) Clone
D) Overlap

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

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

3. The facility has received a clinical validation denial for sepsis. The denial states sepsis is not a clinically valid diagnosis because it does not meet Sepsis-3 criteria. The facility has a policy stating it uses Sepsis-2 criteria.
What is the BEST next step?

A) Have the contracting department work with payors to obtain agreement on how sepsis will be clinically validated.
B) Appeal the denial because all payors must use the hospital's sepsis criteria when reviewing their claims.
C) Remove sepsis from all claims where the diagnosis is not supported by sepsis 3 criteria.
D) Query physicians when Sepsis-3 criteria is not met so they can provide additional documentation to support the diagnosis.

4. The provider was queried because the patient met clinical criteria for acute hypoxic respiratory failure. The response to the query was different than what was expected by the clinical documentation integrity practitioner (CDIP). What should the CDIP do?

A) Record the query response as disagreed
B) Implement the department's escalation process
C) Have a different CDIP query the provider
D) Revise the query and send it back to the provider

5. The most beneficial step to identify post-discharge query opportunities that affect severity of illness, risk of mortality and case weight is to

A) identify normal diagnostic test results that may indicate a possible addition of a secondary diagnosis
B) watch for reportable conditions or conditions that are unambiguous or otherwise complete
C) look for documented conditions that have well supported accompanying clinical criteria
D) determine if only the treatment is documented and there is no diagnosis documented

Solutions: