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AHIMA Certified Documentation Integrity Practitioner Sample Questions:

1. A 27-year-old male patient presents to the emergency room with crampy, right lower quadrant abdominal pain, a low-grade fever (101° Fahrenheit) and vomiting. The patient also has a history of type I diabetes mellitus. A complete blood count reveals mild leukocytosis (13,000/microliter). Abdominal ultrasound is ordered, and the patient is admitted for laparoscopic surgery. The patient is given an injection of neutral protamine Hagedorn insulin, in order to normalize the blood sugar level prior to surgery. Upon discharge, the attending physician documents "right lower quadrant abdominal pain due to possible acute appendicitis or probable Meckel diverticulitis".
What is the proper sequencing of the principal and secondary diagnoses?

A) Acute appendicitis, right lower quadrant abdominal pain, type I diabetes mellitus
B) Right lower quadrant abdominal pain, fever, vomiting, leukocytosis
C) Acute appendicitis, Meckel diverticulitis, type I diabetes mellitus
D) Right lower quadrant abdominal pain, acute appendicitis, Meckel diverticulitis, fever, vomiting, leukocytosis

2. The clinical documentation integrity (CDI) manager is meeting with a steering committee to discuss the adoption of a new CDI program. The plan is to use case mix index (CMI) as a metric of CDI performance.
How will this metric be measured?

A) Month-to-month to show CMI variability as a barometer of a specific month
B) Over time with a focus on high relative weight (RW) procedures that impact these procedures on overall CMI
C) Month-to-month and focus on patient volumes to determine the raise the overall CMI
D) Over time with a focus on particular documentation improvement areas in addition to the overall CMI

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, 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.

4. Which of the following demonstrates the relative severity and complexity of patient treated in the hospital, and is used to evaluate the financial impact of a hospital's clinical documentation integrity (CDI) program?

A) Program for evaluating payment patterns electronic report
B) Present on admission indicators
C) Adjusted case mix index
D) Hospital acquired conditions

5. When there are comparative contrasting diagnoses supported by clinical criteria, the correct action is to

A) not code either diagnosis
B) query for clarification
C) code both diagnoses
D) code the first condition listed

Solutions: