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AHIMA CDIP Exam Syllabus Topics:

AHIMA Certified Documentation Integrity Practitioner Sample Questions:

1. A resident returns to the long-term care facility following hospital care for pneumonia. The physician's orders and progress note state "Continue IV antibiotics for pneumonia - 3 more days, after which time the resident is to have a repeat x-ray to determine status of the pneumonia". Is it appropriate to code the pneumonia in this scenario?

A) No, since the patient needed a repeat x-ray, the condition does not clarify as a diagnosis
B) Yes, J18.9, Pneumonia, unspecified organism, Z79.2 should be coded along with long term antibiotics
C) Yes J18.8, Pneumonia, other specified organism
D) Yes, J18.9, Pneumonia, unspecified organism, should be coded until the condition is resolved

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

3. An otherwise healthy male was admitted to undergo a total hip replacement as treatment for ongoing primary osteoarthritis of the right hip. During the post-operative period, the patient choked on liquids which resulted in aspiration pneumonia as shown on chest x-ray.
Intravenous antibiotics were administered, and the pneumonia was
monitored for improvement with two additional chest x-rays. The patient was discharged to home in stable condition on post-operative day 5.
Final Diagnoses:
1. Primary osteoarthritis of right hip status post uncomplicated total hip replacement
2. Aspiration pneumonia due to choking on liquid episode
What is the correct diagnostic related group assignment?

A) 469 Major Joint Replacement or Reattachment of Lower Extremity with MCC
B) 179 Respiratory Infections and Inflammations without CC/MCC
C) 470 Major Joint Replacement or Reattachment of Lower Extremity without MCC
D) 553 Bone Diseases and Arthropathies with MCC

4. A patient was admitted with complaints of confusion, weakness, and slurred speech. A CT of the head and MRI were performed and resulted in normal findings. Daily aspirin was administered and a speech therapy evaluation was conducted. The final diagnosis on discharge was transient ischemic attack, and cerebrovascular disease was ruled out. What is the correct diagnostic related group assignment?

A) 069 Transient Ischemia
B) 093 Other Disorders of Nervous System without CC/MCC
C) 066 Intracranial Hemorrhage or Cerebral Infarction without CC/MCC
D) 948 Signs and Symptoms without MCC

5. Creating policies and procedures for the query process will help eliminate

A) duplication
B) risk
C) indecision
D) confusion

Solutions: