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AHIMA Certified Documentation Integrity Practitioner Sample Questions:

1. Proposed changes to the inpatient prospective payment system (IPPS) take effect on

A) October 1
B) April 1
C) January 1
D) July 1

2. The clinical documentation integrity (CDI) metrics recently showed a drastic drop in the physician query rate.
What might this indicate to the CDI manager?

A) The decrease in hospital census has caused a lack of query opportunities
B) The program is successful because documentation has improved
C) The loss of a large volume of patients has impacted workflow
D) CDI staff need education on identifying query opportunities

3. Automated registration entries that generate erroneous patient identification-possibly leading to patient safety and quality of care issues, enabling fraudulent activity involving patient identity theft, or providing unjustified care for profit-is an example of a potential breach of:

A) Patient identification and demographic accuracy
B) Auditing integrity
C) Documentation integrity
D) Authorship integrity

4. Which of the following is considered a hospital-acquired condition if not present on admission?

A) Diabetes with hypoglycemia
B) Air leak
C) Blood incompatibility
D) Stage I and II pressure ulcers

5. An 80-year-old male is admitted as an inpatient to the ICU with shortness of breath, productive yellow sputum, and a temperature of 101.2. CXR reveals bilateral pleural effusion and LLL pneumonia. Labs reveal a BUN of 42 and a creatinine level of 1.500.
The patient is given Zithromax 500 mg. IV, NS IV, and Lasix 40 mg tabs 2x/day. The attending physician documents bilateral pleural effusion, LLL pneumonia, and kidney failure. Two days later, the renal consult documents AKI with acute tubular necrosis (ATN). The correct principal and secondary diagnoses are

A) PDx: LLL pneumonia
SDx: Bilateral pleural effusion, kidney failure
B) PDx: LLL pneumonia
SDx: AKI with ATN, bilateral pleural effusion
C) PDx: AKI with ATN
SDx: LLL pneumonia, bilateral pleural effusion
D) PDx: Bilateral pleural effusion
SDx: LLL pneumonia, kidney failure

Solutions: