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AHIMA Certified Documentation Integrity Practitioner Sample Questions:

1. A patient receives a blood transfusion after a 400 ml blood loss during surgery. The clinical documentation integrity practitioner (CDIP) queries the physician for an associated diagnosis. The facility does not maintain queries as part of the permanent health record. What does the physician need to document for the CDIP to record the query as answered and agreed?

A) That the blood loss was not clinically significant
B) The associated diagnosis and the clinical rationale in the progress notes
C) The associated diagnosis directly on the query form
D) A cause-and-effect relationship between anemia and the underlying cause

2. The best approach in resolving unanswered queries is to

A) review the facility's query policies and procedures
B) notify the coding team of the physician's unanswered query
C) contact the physician repeatedly until he/she responds to the query
D) notify the physician advisor/champion that the physician has not responded to the query

3. When there is a discrepancy between the clinical documentation integrity practitioner's (CDIP's) working DRG and the coder's final DRG, which of the following is considered a fundamental element that must be in place for a successful resolution?

A) Physician and CDIP interaction
B) Executive oversight
C) Physician advisor/champion involvement
D) Coder and CDIP interaction

4. A patient was admitted for high fever and pain in umbilical region. During the second day of the hospital stay, the patient stood up to use the restroom and fell on the floor, resulting in a broken chin bone. A physician noted the fall on the second day in progress note. Which further clarification should be done regarding present on admission (POA) indicator of fall?

A) Query physician for POA
B) Bring this case up in weekly Health Information Management meetings for further action
C) Take the case to physician advisor/champion to discuss further action
D) No query is needed

5. Which entity has the following regulation?
A medical history and physical examination be completed and documented for each patient no more than 30 days before or 24 hours after admission or registration, but prior to surgery or a procedure requiring anesthesia services.

A) Office for Civil Rights
B) Office of Inspector General
C) Office of the National Coordinator for Health Information Technology
D) Centers for Medicare & Medicaid Services

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