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AHIMA Certified Documentation Integrity Practitioner Sample Questions:
1. 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, right lower quadrant abdominal pain, type I diabetes mellitus
C) Right lower quadrant abdominal pain, fever, vomiting, leukocytosis
D) Acute appendicitis, Meckel diverticulitis, type I diabetes mellitus
2. A clinical documentation integrity practitioner (CDIP) generates a concurrent query and continues to follow retrospectively; however, the coder releases the bill before the query is answered. The CDIP wonders if it is appropriate to re-bill the account if the physician answers the query after the bill has dropped. Which policy should the hospital follow to avoid a compliance risk?
A) A post bill query is not appropriate when an error is found after an audit.
B) A post-bill query rarely occurs as a result of an audit or other internal monitor.
C) A second bill should not be submitted when the first bill was incomplete.
D) A rebilling is permissible when queries are answered after the initial bill.
3. A physician documented the specific site of the malignancy in the medical record documentation; however, the coder is unable to locate a specific entry in the ICD-10- CM Alphabetical Index to match the specified diagnosis. Which abbreviation used in the Alphabetical Index will assist the coder in assigning the appropriate diagnosis code for the specified condition?
A) NOS
B) OCE
C) NEC
D) DRG
4. After one year, the clinical documentation integrity (CDI) program has become stagnant, and the manager plans to reinvigorate the program to better reflect the CDI efforts in the organization. What can the manager do to ensure program success?
A) Identify key metrics to develop program measures for coders
B) Expand the CDI program to larger areas in outpatient clinics
C) Prioritize to focus on efforts with the largest return on investment
D) Establish a CDI steering committee to build a strong foundation
5. 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 APR-DRGs and develop education plan for CDI team and physicians
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 cases by physicians that have a higher SOI/ROM for education plan
Solutions:
Question # 1 Answer: B | Question # 2 Answer: D | Question # 3 Answer: C | Question # 4 Answer: D | Question # 5 Answer: A |