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AHIMA Certified Documentation Integrity Practitioner Sample Questions:

1. A patient's progress note states "The patient has chronic systolic heart failure". After reviewing clinical indicators suggestive of an exacerbation of systolic heart failure, the clinical documentation integrity practitioner (CDIP) queries the physician to clarify the current acuity of the diagnosis. Which subsequent documentation in the health record suggests the provider did not understand the query?

A) The patient has acute on chronic systolic heart failure.
B) The patient has chronic systolic heart failure.
C) The patient has decompensated systolic heart failure.
D) The patient did have an exacerbation of heart failure.

2. Which of the following clinical documentation integrity (CDI) dashboard metrics is frequently used to help evaluate the credibility of CDI practitioner queries and the success of the CDI program?

A) CDI agreement rate
B) CDI query rate
C) Provider response rate
D) Provider agreement rate

3. Which of the following is the definition of an Excludes 2 note in ICD-10-CM?

A) This is not a convention found in ICD-10-CM
B) Two codes can be used together to completely describe the condition
C) Neither of the codes can be assigned
D) Only one code can be assigned to completely describe the condition

4. Review the following query to determine if it is compliant:
Dr. Jones, this patient had a sodium level of 126 on admission and was started on a 0.9% saline IV. Can you indicate what condition is being treated?
Dehydration
Hyponatremia
Hypernatremia
Chronic kidney disease (indicate stage)
Other (please specify)

A) Yes, query is compliant as it provides clinical indicators and several options for response.
B) No, query is noncompliant as one of the multiple-choice options is clinically irrelevant.
C) Yes, query is compliant as it offers the minimum number of multiple-choice answers ..
D) No, query is noncompliant as it does not provide the option of "unable to determine".

5. When queries are part of the health record, which of the following physician privilege could be suspended if the provider receives too many deficiencies due to incomplete records for failure to respond to queries?

A) Surgical
B) Consulting
C) Admitting
D) Credentialing

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