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AHIMA Certified Documentation Integrity Practitioner Sample Questions:

1. Identify the error in the following query:
This patient's echocardiogram showed an ejection fraction of 25%. The chest x-ray showed congestive heart failure (CHF). The patient was prescribed Lasix and an angiotensin-converting enzyme inhibitor (ACEI). Is this patient's CHF systolic?

A) The query does not contain clinical indicators.
B) The query is leading.
C) The query contains irrelevant information.
D) The query is unclear.

2. When writing a compliant query, best practice is to

A) include all relevant clinical indicators
B) use a yes/no query format for specificity of a diagnosis
C) direct the physician to a specific diagnosis
D) use the term "possible" to describe a condition or diagnosis when uncertain if the diagnosis is present

3. For inpatients with a discharge principal diagnosis of acute myocardial infarction, aspirin must be taken within
24 hours of arrival unless a contraindication to aspirin is
documented. How should this be documented in the health record?

A) The name of the medication (aspirin) and the date it was last administered
B) The name of the medication (aspirin), the date and location where it was last administered
C) The name of the medication (aspirin), the date, time and location where it was last administered
D) The name of the medication (aspirin), the date and time it was last administered

4. A patient presents to the emergency room with complaint of cough with thick yellow/greenish sputum, and generalized pain. Admitting vital signs are noted below and sputum culture performed. The patient is admitted with septicemia due to pneumonia and has received 2L of normal saline and piperacillin/ tazobactam. After all results were reviewed, on day 2, the hospitalist continued to document septicemia due to pneumonia.
White blood count BC 18,000
Temperature 101.5
Heart rate 110
Respiratory rate 24
Blood pressure 95/67
Sputum culture (+) klebsiella pneumoniae
Which diagnosis implies that a query was sent and answered?

A) Severe sepsis with pneumonia due to klebsiella pneumoniae
B) Septicemia due to klebsiella pneumoniae
C) Sepsis with pneumonia due to klebsiella pneumoniae
D) Sepsis with respiratory failure due to pneumonia

5. The third quarter target concurrent physician query response rate for each physician in a hospital gastroenterology department was 80%. Nine physicians met or exceeded this metric; however, two physicians had third quarter concurrent physician query response rates of 19% and 64%. What is the best course of action for the clinical documentation integrity (CDI) physician advisor/champion?

A) Schedule a group meeting with all physicians
B) Schedule a meeting with the chair of the gastroenterology department
C) Schedule individual meetings with each physician
D) Schedule individual meetings with each low-performing physician

Solutions: