• Exam Code: CDIP
  • Exam Name: Certified Documentation Integrity Practitioner
  • Certification Provider: AHIMA
  • Corresponding Certification:AHIMA CDI
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AHIMA Certified Documentation Integrity Practitioner Sample Questions:

1. A 50-year-old with a history of stage II lung cancer is brought to the emergency department with severe dyspnea. The patient underwent the last round of chemotherapy
3 days ago. Vital signs reveal a temperature of 98.4, a heart rate of 98, a respiratory rate of 28, and a blood pressure of 124/82. O2 saturation on room air is 92%. The patient is 5'5"and weighs 98 lbs. The registered dietitian notes the patient is malnourished with BMI of 19.
Chest x-ray reveals a large pleural effusion in the right lung.
Thoracentesis is performed and 1000 cc serosanguinous fluid is removed. The admitting diagnosis is large right lung pleural effusion related to lung cancer stage II, documented multiple times. What post discharge query opportunity should be sent to the physician that will affect severity of illness (SOI)/risk of mortality (ROM)?

A) Query for malignant pleural effusion
B) Query for protein calorie malnutrition
C) Query if the malignant pleural effusion is the reason for admission
D) Query for a diagnosis associated with the dietician's finding of malnutrition


2. When a change in departmental workflow is necessary, the first step is to

A) re-engineer the process
B) assess the current workflow
C) set realistic timelines
D) define the gaps and solutions


3. An 86-year-old female is brought to the emergency department by her daughter. The patient complains of feeling tired, weak and excessive sleeping. The patient's daughter comments that patient's mental condition has not been the same. Lab results are unremarkable except for a sodium level of 119, a BUN of 22, and a creatinine of 1.35. The patient receives normal saline IV infusing at 100 cc/hr. The admitting diagnosis is weakness, altered mental status and dehydration. Which of the following queries is presented in an ethical manner thus avoiding potential fraud and/or compliance issues?

A) Patient is feeling tired, weak, sleeping a lot and has altered mental status. Sodium is 119 and she is on NS IV at 100 cc/hr. Is the altered mental status related to the sodium of 119?
B) Patient's sodium is 119 and she is on NS IV at 100 cc/hr, is this clinically significant? If so, please document a corresponding diagnosis related to this lab result.
C) Patient's sodium is 119 and she is on NS IV at 100 cc/hr, does patient have hyponatremia?
D) Patient is feeling tired, weak, sleeping a lot and has altered mental status. Sodium is 119 and she is on NS IV at 100 cc/hr, please clarify the clinical significance of the lab result.


4. A patient was admitted due to possible pneumonia. Chest x-ray was positive for infiltrate. The physician's documentation indicates that the patient continues to smoke cigarettes despite recommendations to quit. Patient also has a long-term history of chronic obstructive pulmonary disease (COPD) due to smoking. IV antibiotic was given for pneumonia along with oral Prednisone and Albuterol for COPD.
Discharge diagnoses:
1. Pneumonia
2. COPD
3. Current smoker
What is the correct diagnostic related group assignment?

A) DRG 190 Chronic Obstructive Pulmonary Disease with MCC
B) DRG 194 Simple Pneumonia and Pleurisy without CC/MCC
C) DRG 202 Bronchitis and Asthma with CC/MCC
D) DRG 204 Respiratory Signs and Symptoms


5. A 56-year-old male patient complains of feeling fatigued, has nausea & vomiting, swelling in both legs.
Patient has history of chronic kidney disease (CKD) stage III,
coronary artery disease (CAD) & hypertension (HTN). He is on Lisinopril. Vital signs: BP 160/80, P 84, R 20, T 100.OF. Labs: WBC 11.5 with 76% segs, GFR 45. CXR showed slight left lower lobe haziness. Patient was admitted for acute kidney injury (AKI) with acute tubular necrosis (ATN). He was scheduled for hemodialysis the next day. Two days after admission patient started coughing, fever of 101.8F, CXR showed left lower lobe infiltrate, possible pneumonia. Attending physician documented that patient has pneumonia and ordered Rocephin IV. How should the clinical documentation integrity practitioner (CDIP) interact with the physician to clarify whether or not the pneumonia is a hospital-acquired condition (HAC)?

A) Dr. Adair, please indicate if the patient's pneumonia was present on admission (POA) based on the initial chest x-ray?
B) No need to interact with the physician because it is obvious the pneumonia developed after admission, therefore, not present on admission.
C) No need to query the physician because even if the pneumonia is considered a HAC and cannot be used as an MCC, ATN is also an MCC.
D) Dr. Adair, in your clinical opinion, do you think that the patient's acute kidney injury with ATN exacerbated the patient's pneumonia?


Solutions:

Question # 1
Answer: A
Question # 2
Answer: B
Question # 3
Answer: D
Question # 4
Answer: A
Question # 5
Answer: A

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