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AHIMA Certified Documentation Integrity Practitioner Sample Questions:

1. Besides the physician advisor/champion, who should be included as a key stakeholder in the clinical documentation integrity (CDI) steering committee to promote CDI initiatives?

A) Manager of Surgical Services
B) Director of Informatics
C) Director of Risk Management
D) Manager of HIM/Coding

2. A 70-year-old severely malnourished nursing home patient is admitted for a pressure ulcer covered by eschar on the right hip. The provider is queried to clarify the stage of the pressure ulcer. Because the wound has not been debrided, the provider responds "unable to determine".
How will the stage of this pressure ulcer be coded?

A) Stage III pressure ulcer
B) Stage IV pressure ulcer
C) Undetermined stage pressure ulcer
D) Unstageable pressure ulcer

3. When are concurrent queries initiated?

A) Before patient is admitted
B) While the patient is hospitalized
C) After the health record has been coded
D) After discharge of the patient

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

5. Which of the following diagnosis is MOST likely to trigger a second level review?

A) Acute kidney injury
B) Malnutrition
C) Heart failure
D) Pneumonia

Solutions: