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AHIMA Certified Documentation Integrity Practitioner Sample Questions:

1. 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.

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

3. A hospital noticed a 30% denial rate in Medicare claims due to lack of clinical documentation, placing the hospital at risk of multiple Medicare violations. What step should the clinical documentation integrity (CDI) manager take to help avoid future Medicare violations?
Collaborate with physician advisor/champion and revenue cycle manager
Instruct the billing department to write off claims with insufficient documentation

A) Prevent submission of claims for improper documentation
B) Assign pre-billing claim review duties to physicians

4. A clinical documentation integrity practitioner (CDIP) has been successful in getting physicians to respond to queries. However, when the CDIP poses a query to a specific doctor, there is no response at all. The CDIP has tried face-to-face conversations, calling, emails, texts, but still gets no response. What is the next step the CDIP should take?

A) Report the doctor to the Vice President of Medical Affairs so the doctor understands the importance of clinical documentation
B) Hold a meeting with the CDI director and the doctor to find out why the doctor is not responding to the queries
C) Warn the other CDIPs that the doctor is a non-responder and to forego querying
D) Elevate the issue to the physician advisor/champion after the CDI supervisor has reviewed the case and deemed the query appropriate

5. Which member of the clinical documentation integrity (CDI) team can help provide peer-to-peer level of education on the importance of accurate documentation and query responses?

A) CDI practitioner
B) Physician advisor/champion
C) CDI manager
D) Chief Financial Officer

Solutions: