AHIMA Certified Documentation Integrity Practitioner - CDIP certification

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AHIMA CDIP Exam Syllabus Topics:

AHIMA Certified Documentation Integrity Practitioner Sample Questions:

1. A query should include

A) the impact on quality
B) relevant clinical indicators
C) information from previous encounters
D) the impact of reimbursement

2. Review the following query to determine if it is compliant:
Dr. Jones, this patient had a sodium level of 126 on admission and was started on a 0.9% saline IV. Can you indicate what condition is being treated?
Dehydration
Hyponatremia
Hypernatremia
Chronic kidney disease (indicate stage)
Other (please specify)

A) No, query is noncompliant as one of the multiple-choice options is clinically irrelevant.
B) Yes, query is compliant as it provides clinical indicators and several options for response.
C) Yes, query is compliant as it offers the minimum number of multiple-choice answers ..
D) No, query is noncompliant as it does not provide the option of "unable to determine".

3. A clinical documentation integrity practitioner (CDIP) generates a concurrent query and continues to follow retrospectively; however, the coder releases the bill before the query is answered. The CDIP wonders if it is appropriate to re-bill the account if the physician answers the query after the bill has dropped. Which policy should the hospital follow to avoid a compliance risk?

A) A post-bill query rarely occurs as a result of an audit or other internal monitor.
B) A rebilling is permissible when queries are answered after the initial bill.
C) A second bill should not be submitted when the first bill was incomplete.
D) A post bill query is not appropriate when an error is found after an audit.

4. A 75-year-old, diabetic patient with a history of osteoporosis, being treated with Fosamax, who sustained a femur fracture after falling down three stairs. The provider's documentation indicates to admit the patient for a traumatic femur fracture and an orthopedics consult is pending. The clinical documentation integrity practitioner (CDIP) decides to query for a possible link between osteoporosis and the femur fracture. Which of the following is the most compliant query based on the most recent AHIMA/ACDIS query practice brief?

A) Patient admitted for a femur fracture with a history of osteoporosis being treated with Fosamax. Could diabetes be a contributing factor in the femur fracture?
B) Patient admitted for a femur fracture with a history of osteoporosis being treated with Fosamax. In your medical opinion, is this fracture consistent with an osteoporotic pathological fracture?
C) Patient admitted for a femur fracture with a history of osteoporosis being treated with Fosamax. Please clarify the cause of the femur fracture in your next note and/or the discharge summary.
D) Patient admitted for a femur fracture with a history of osteoporosis being treated with Fosamax. Please document "femur fracture due to osteoporosis" in your next progress note to demonstrate a link between the two diagnoses.

5. Which of the following is the definition of an Excludes 2 note in ICD-10-CM?

A) Neither of the codes can be assigned
B) Only one code can be assigned to completely describe the condition
C) This is not a convention found in ICD-10-CM
D) Two codes can be used together to completely describe the condition

Solutions: