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AHIMA CDIP Exam Syllabus Topics:

AHIMA Certified Documentation Integrity Practitioner Sample Questions:

Question #1

A patient presents to the emergency room with complaint of cough with thick yellow/greenish sputum, and generalized pain. Admitting vital signs are noted below and sputum culture performed. The patient is admitted with septicemia due to pneumonia and has received 2L of normal saline and piperacillin/ tazobactam. After all results were reviewed, on day 2, the hospitalist continued to document septicemia due to pneumonia.
White blood count BC 18,000
Temperature 101.5
Heart rate 110
Respiratory rate 24
Blood pressure 95/67
Sputum culture (+) klebsiella pneumoniae
Which diagnosis implies that a query was sent and answered?

A. Sepsis with respiratory failure due to pneumonia
B. Sepsis with pneumonia due to klebsiella pneumoniae
C. Severe sepsis with pneumonia due to klebsiella pneumoniae
D. Septicemia due to klebsiella pneumoniae

Question #2

A modifier may be used in CPT and/or HCPCS codes to indicate

A. a service or procedure was increased or reduced
B. a service or procedure was performed by one provider
C. a service or procedure resulted in expected outcomes
D. a service or procedure was performed in its entirety

Question #3

A patient is admitted due to pneumonia. On day 1, a sputum culture is positive for psuedomonas bacteria. If the physician is queried and agrees that the patient has pseudomonas pneumonia, this specificity would

A. meet medical necessity
B. not increase relative weight
C. not meet medical necessity
D. increase relative weight

Question #4

An 80-year-old male is admitted as an inpatient to the ICU with shortness of breath, productive yellow sputum, and a temperature of 101.2. CXR reveals bilateral pleural effusion and LLL pneumonia. Labs reveal a BUN of 42 and a creatinine level of 1.500.
The patient is given Zithromax 500 mg. IV, NS IV, and Lasix 40 mg tabs 2x/day. The attending physician documents bilateral pleural effusion, LLL pneumonia, and kidney failure. Two days later, the renal consult documents AKI with acute tubular necrosis (ATN). The correct principal and secondary diagnoses are

A. PDx: LLL pneumonia
SDx: Bilateral pleural effusion, kidney failure
B. PDx: LLL pneumonia
SDx: AKI with ATN, bilateral pleural effusion
C. PDx: AKI with ATN
SDx: LLL pneumonia, bilateral pleural effusion
D. PDx: Bilateral pleural effusion
SDx: LLL pneumonia, kidney failure

Question #5

A patient is admitted for chronic obstructive pulmonary disease (COPD) exacerbation. The patient is on 3L of home oxygen and is treated during admission with 3L of oxygen. The most appropriate action is to

A. code the diagnoses of COPD exacerbation and chronic respiratory failure
B. query the provider to see if respiratory insufficiency is supported by the health record
C. query the provider to see if acute on chronic respiratory failure is supported by the health record
D. query the provider to see if chronic respiratory failure is supported by the health record

Solutions: