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AHIMA CDIP Exam Syllabus Topics:

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

2. 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, please clarify the clinical significance of the lab result.
B) 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?
C) Patient's sodium is 119 and she is on NS IV at 100 cc/hr, does patient have hyponatremia?
D) 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.

3. Which of the following may result in an incomplete health record deficiency being assigned to a provider?

A) A retrospective query
B) An outstanding query
C) A concurrent query
D) A quality query

4. A patient is admitted for chronic obstructive pulmonary disease (COPD) exacerbation. The patient is on 3L of home oxygen and is treated during admission with 3L of oxygen. The most appropriate action is to

A) query the provider to see if acute on chronic respiratory failure is supported by the health record
B) code the diagnoses of COPD exacerbation and chronic respiratory failure
C) query the provider to see if respiratory insufficiency is supported by the health record
D) query the provider to see if chronic respiratory failure is supported by the health record

5. Based on the flowchart below, at what point might the clinical documentation integrity practitioner (CDIP) enlist the help of the physician advisor/champion?

A) C - Retrospective query opportunity identified
B) D - No retrospective query opportunity identified
C) E - Physician agrees with query and documents in MR
D) H - Physician fails to respond tocquery

Solutions: