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AHIMA Certified Documentation Integrity Practitioner Sample Questions:

1. Automated registration entries that generate erroneous patient identification-possibly leading to patient safety and quality of care issues, enabling fraudulent activity involving patient identity theft, or providing unjustified care for profit-is an example of a potential breach of:

A) Authorship integrity
B) Auditing integrity
C) Documentation integrity
D) Patient identification and demographic accuracy

2. A 77-year-old male with chronic obstructive pulmonary disease (COPD) is admitted as an inpatient with severe shortness of breath. The patient is placed on oxygen at 2 liters per minute via nasal cannula. History reveals that the patient is on oxygen nightly at home. CXR is unremarkable. The most compliant query is

A) Patient has COPD and is on oxygen every night at home and has been on continuous oxygen since admission, please document chronic respiratory failure, hypoxia, acute on chronic respiratory failure.
B) Patient has COPD, and is on nocturnal oxygen at home and is on continuous oxygen since admission.
Please indicate if you are treating one of these diagnoses: chronic respiratory failure, acute respiratory failure, acute on chronic respiratory failure, unable to determine, other.
C) Patient has COPD, and is on nocturnal oxygen at home and is on continuous oxygen since admission.
Please order further tests so the patient's severity of illness can be captured with the most accurate coding assignment.
D) Patient has COPD and is on oxygen every night at home and has been on continuous oxygen since admission. Based on these indications, please document chronic respiratory failure, acute respiratory failure, acute on chronic respiratory failure.

3. Which of the following falls under the False Claims Act?

A) Missing charges
B) Missing modifiers
C) Missing diagnosis codes
D) Unbundling services

4. A 94-year-old female patient is admitted with altered mental status and inability to move the left side of her body. She is diagnosed with a cerebral vascular accident with left sided weakness. The patient is ambidextrous, but the physician does not specify the predominance of the affected side. The default code is

A) ambidextrous
B) preferred
C) non-dominant
D) dominant

5. Which of these medical conditions would a clinical documentation integrity practitioner (CDIP) expect to be treated with Levophed?

A) Multiple sclerosis
B) Acute kidney failure
C) Septic shock
D) Acute respiratory failure

Solutions: