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AHIMA Certified Documentation Integrity Practitioner Sample Questions:
1. A key physician approaches the director of the coding department about the new emphasis associated with clinical documentation integrity (CDI). The physician does not support the program and believes the initiative will encourage inappropriate billing.
How should the director respond to the concerns?
A) Inform the physician that changes must be made
B) Involve the physician advisor/champion in addressing the medical staff's concerns
C) Refer the physician to the finance department to discuss required billing changes
D) Develop an administrative panel to oversee CDI process
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'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.
B) Patient's sodium is 119 and she is on NS IV at 100 cc/hr, does patient have hyponatremia?
C) 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?
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.
3. The most beneficial step to identify post-discharge query opportunities that affect severity of illness, risk of mortality and case weight is to
A) watch for reportable conditions or conditions that are unambiguous or otherwise complete
B) look for documented conditions that have well supported accompanying clinical criteria
C) determine if only the treatment is documented and there is no diagnosis documented
D) identify normal diagnostic test results that may indicate a possible addition of a secondary diagnosis
4. The clinical documentation integrity (CDI) manager reviewed all payer refined-diagnosis related groups (APR-DRG) benchmarking data and has identified potential opportunities for improvement. The manager hopes to develop a work plan to target severity of illness (SOI)/risk of mortality (ROM) by service line and providers. How can the manager gain more information about this situation?
A) Audit focused APR-DRGs and develop education plan for CDI team and physicians
B) Audit cases for missed diagnosis by the CDI practitioner to target in the education plan
C) Audit cases that have high SOI/ROM assigned by coders for education and follow-up
D) Audit focused cases by physicians that have a higher SOI/ROM for education plan
5. Hospital-acquired condition pay provisions apply only to
A) long-term acute care hospitals
B) critical access hospitals
C) inpatient prospective payment system hospitals
D) inpatient psychiatric hospitals
Solutions:
Question # 1 Answer: B | Question # 2 Answer: D | Question # 3 Answer: C | Question # 4 Answer: A | Question # 5 Answer: C |