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AHIMA Certified Documentation Integrity Practitioner Sample Questions:

1. The clinical documentation integrity (CDI) manager reviewed all payer refined-diagnosis related groups (APR-DRG) benchmarking data and has identified potential opportunities for improvement. The manager hopes to develop a work plan to target severity of illness (SOI)/risk of mortality (ROM) by service line and providers. How can the manager gain more information about this situation?

A) Audit focused cases by physicians that have a higher SOI/ROM for education plan
B) Audit cases for missed diagnosis by the CDI practitioner to target in the education plan
C) Audit cases that have high SOI/ROM assigned by coders for education and follow-up
D) Audit focused APR-DRGs and develop education plan for CDI team and physicians

2. A 27-year-old male patient presents to the emergency room with crampy, right lower quadrant abdominal pain, a low-grade fever (101° Fahrenheit) and vomiting. The patient also has a history of type I diabetes mellitus. A complete blood count reveals mild leukocytosis (13,000/microliter). Abdominal ultrasound is ordered, and the patient is admitted for laparoscopic surgery. The patient is given an injection of neutral protamine Hagedorn insulin, in order to normalize the blood sugar level prior to surgery. Upon discharge, the attending physician documents "right lower quadrant abdominal pain due to possible acute appendicitis or probable Meckel diverticulitis".
What is the proper sequencing of the principal and secondary diagnoses?

A) Right lower quadrant abdominal pain, acute appendicitis, Meckel diverticulitis, fever, vomiting, leukocytosis
B) Acute appendicitis, Meckel diverticulitis, type I diabetes mellitus
C) Acute appendicitis, right lower quadrant abdominal pain, type I diabetes mellitus
D) Right lower quadrant abdominal pain, fever, vomiting, leukocytosis

3. The clinical documentation integrity (CDI) team in a hospital is initiating a project to change the unacceptable documentation behaviors of some physicians. What strategy should be part of a project aimed at improving these behaviors?

A) Add a physician advisor/champion to the CDI team
B) Expand use of coding queries by CDI team
C) Encourage physician-nurse cooperation
D) Alter the physician documentation requirements

4. The physician advisor/champion needs to provide ongoing education regarding coding and reimbursement regulations to the

A) Health Information Management coding staff
B) organization senior administration staff
C) organization's medical and surgical staff
D) clinical documentation integrity staff

5. A clinical documentation integrity (CDI) program that is compliant with regulations from the facility's payors results in

A) need for more CDI staff
B) meeting external benchmarks
C) higher overall program cost
D) less risk from audits

Solutions: