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

2. Which of the following diagnosis is MOST likely to trigger a second level review?

A) Pneumonia
B) Malnutrition
C) Acute kidney injury
D) Heart failure

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

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

4. A patient falls off a ladder and undergoes a right femur procedure. Three weeks later, the patient returns to the hospital for removal of the external fixation device. The ICD-10-CM 7th character code value should indicate

A) subsequent
B) sequela
C) initial
D) aftercare

5. A patient has a history of asthma and presents with complaints of fever, cough, general body aches, and lethargy. The patient's child was recently diagnosed with influenza. Wheezing is heard on exam. The physician documents the diagnosis as asthma exacerbation and orders nebulizer treatments of Albuterol and a 5-day course of oral Prednisone. The clinical documentation integrity practitioner (CDIP) is unsure which signs and symptoms are inherent to asthma. Which reference resource should be used to obtain this information?

A) AMA CPT Assistant
B) The Merck Manual
C) Medical Dictionary
D) Physician's Desk Reference

Solutions: