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AHIMA CDIP Exam Syllabus Topics:

AHIMA Certified Documentation Integrity Practitioner Sample Questions:

1. In order to best demonstrate the impact of clinical documentation on severity of illness and risk of mortality, which of the following examples is the most effective for physicians in a hospital?

A) Examples from the hospital's actual cases
B) The latest Medicare Provider and Analysis Review data
C) Emphasize the Medicare requirements for documentation
D) Explanations on how severity of illness and risk of mortality impact reimbursement

2. A patient was admitted with complaints of confusion, weakness, and slurred speech. A CT of the head and MRI were performed and resulted in normal findings. Daily aspirin was administered and a speech therapy evaluation was conducted. The final diagnosis on discharge was transient ischemic attack, and cerebrovascular disease was ruled out. What is the correct diagnostic related group assignment?

A) 093 Other Disorders of Nervous System without CC/MCC
B) 948 Signs and Symptoms without MCC
C) 066 Intracranial Hemorrhage or Cerebral Infarction without CC/MCC
D) 069 Transient Ischemia

3. An otherwise healthy male was admitted to undergo a total hip replacement as treatment for ongoing primary osteoarthritis of the right hip. During the post-operative period, the patient choked on liquids which resulted in aspiration pneumonia as shown on chest x-ray.
Intravenous antibiotics were administered, and the pneumonia was
monitored for improvement with two additional chest x-rays. The patient was discharged to home in stable condition on post-operative day 5.
Final Diagnoses:
1. Primary osteoarthritis of right hip status post uncomplicated total hip replacement
2. Aspiration pneumonia due to choking on liquid episode
What is the correct diagnostic related group assignment?

A) 553 Bone Diseases and Arthropathies with MCC
B) 469 Major Joint Replacement or Reattachment of Lower Extremity with MCC
C) 470 Major Joint Replacement or Reattachment of Lower Extremity without MCC
D) 179 Respiratory Infections and Inflammations without CC/MCC

4. The clinical documentation integrity (CDI) manager is reviewing physician benchmarks and notices a low-severity level being measured against average length of stay.
What should the CDI manager keep in mind when discussing this observation with physicians?

A) The diagnosis with a higher degree of specificity has a lower severity of illness.
B) The query rate is too high while the agreement rate is low.
C) The query response rate directly correlates to quality reports.
D) The indicator is a key factor of measurement for quality reports.

5. A hospital noticed a 30% denial rate in Medicare claims due to lack of clinical documentation, placing the hospital at risk of multiple Medicare violations. What step should the clinical documentation integrity (CDI) manager take to help avoid future Medicare violations?
Collaborate with physician advisor/champion and revenue cycle manager
Instruct the billing department to write off claims with insufficient documentation

A) Prevent submission of claims for improper documentation
B) Assign pre-billing claim review duties to physicians

Solutions: