Certified Documentation Integrity Practitioner Practice Test

AHIMA-CDIP exam Format | Course Contents | Course Outline | exam Syllabus | exam Objectives

Exam Code: CDIP
Exam Name: Certified Documentation Integrity Practitioner
Number of Questions: 100 multiple-choice questions
Time Allotted: 2 hours (120 minutes)
Passing Score: 300 (on a scale of 100–400)
Exam Format: Computer-based (CBT) at Pearson VUE testing centers or online proctored

- Clinical Coding Practice
- Use reference resources for code assignment
- Identify the principal and secondary diagnoses in order to accurately reflect the patient’s hospital course
- Assign and sequence diagnosis and procedure codes
- Apply coding conventions and guidelines related to diagnosis and procedure codes
- Understand the assignment of the working and final DRG
- Communicate with the coding/HIM staff to resolve discrepancies between the working and final DRGs- and to ensure coding and reimbursement updates are incorporated into practice

- Education and Leadership Development
- Promote CDI efforts throughout the organization and health system- including administration
- Create and nurture working relationships to support collaboration across multi-disciplinary teams
- Develop documentation improvement projects
- Collaborate with physician champions to promote CDI initiatives
- Develop CDI policies and procedures in accordance with AHIMA practice briefs
- Determine facility requirements for documentation of query responses in the record to establish official policy and procedures related to CDI query activities
- Recognize a chain of command for resolving unanswered queries
- Facilitate clinical documentation integrity by identifying educational Topics and delivery methods for effective learning for an audience
- Articulate the implications of accurate documentation and coding with respect to research- public health reporting- case management- and reimbursement

- Record Review & Document Clarification
- Demonstrate comprehension of clinical documentation in health records
- Identify and prioritize cases as part of the CDI review process
- Identify gaps in documentation that may impact patient quality of care- code assignment- or reimbursement (e.g.- command of disease process- clinical concepts- clinical validation opportunities- etc.)
- Apply industry current best practices pertaining to query development and query processes
- Identify strategies for obtaining query responses from providers and ensure provider query response is documented in the health record
- Interact with providers to clarify documentation opportunities within the health record (e.g.- patient quality indicators- Present on Admission (POA)- acuteness/chronicity- complications- etc.)
- Identify post-discharge query opportunities

- CDI Metrics & Statistics
- Identify common dashboard metrics and monitor CDI departmental performance
- Perform quality audits of CDI content to ensure compliance with institutional policies & procedures or national guidelines
- Track metrics and interpret trends related to the physician query process (e.g.- CDI perspective vs provider perspective)
- Track and interpret data for physician benchmarking and trending
- Compare institution with external institutional benchmarks
- Identify common key performance metrics for CDI professionals
- Use CDI data to adjust departmental workflow

- Compliance
- Apply AHIMA and other industry standards in support of ethical CDI best practices
- Monitor changes in the regulatory environment applicable to CDI activities to maintain compliance with all applicable agencies
- Identify risks associated with technology (e.g.- electronic health records- natural language processing (NLP)- computer-assisted coding- etc.)
- Identify situations when second level reviews are appropriate
- Understand and appropriately use clinical validation queries
- Identify and address non-compliant queries as part of a CDI workflow
- Apply policies regarding various stages of the query process and time frames- including retention of queries- to avoid compliance risk

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Question: 578
A patient undergoes a coronary artery bypass graft (CABG) using a saphenous vein graft. The operative
report notes three coronary arteries bypassed. The provider documents "CABG" without details. The
CDIP queries for clarification, and the provider confirms "three-vessel CABG with saphenous vein
graft." What is the correct ICD-10-PCS code?
A. 021109W - Bypass coronary artery, one artery, from coronary artery with autologous venous tissue,
open approach
B. 021209W - Bypass coronary artery, two arteries, from coronary artery with autologous venous tissue,
open approach
C. 021409W - Bypass coronary artery, four or more arteries, from coronary artery with autologous
venous tissue, open approach
D. 021309W - Bypass coronary artery, three arteries, from coronary artery with autologous venous tissue,
open approach
Answer: D
Explanation: The query confirms a three-vessel CABG with a saphenous vein graft, making 021309W the
correct ICD-10-PCS code for bypassing three coronary arteries with autologous venous tissue, open
approach.
Question: 579
A patient with a history of COPD is admitted with respiratory distress. Labs show pH 7.32, pCO2 55
mmHg, and HCO3 28 mEq/L. The physician documents "COPD exacerbation." The CDIP identifies a
gap in documentation regarding the acuity of respiratory failure. Which query best addresses this gap?
A. Was the respiratory distress present on admission?
B. Is the COPD exacerbation related to pneumonia?
C. Please document "acute on chronic respiratory failure" in the next note.
D. Can you clarify if the respiratory distress is due to acute respiratory failure based on pH 7.32 and
pCO2 55 mmHg?
Answer: D
Explanation: The query "Can you clarify if the respiratory distress is due to acute respiratory failure
based on pH 7.32 and pCO2 55 mmHg?" is compliant as it uses clinical indicators (abnormal arterial
blood gas values) to prompt clarification without leading to a specific diagnosis. "Is the COPD
exacerbation related to pneumonia?" introduces a condition not supported by the scenario. "Please
document 'acute on chronic respiratory failure' in the next note" is leading and non-compliant. "Was the
respiratory distress present on admission?" does not address the acuity gap.
Question: 580
During a weekly CDI team meeting, a CDIP identifies that a physician consistently fails to respond to
concurrent queries regarding the acuity of chronic systolic heart failure exacerbation. According to best
practice and chain of command, what should the CDIP do next if the physician does not answer the query
after two attempts?
A. Escalate the issue to the CDI department manager for intervention
B. Document the physician's non-response and close the query
C. Directly contact the physician's department chair for a response
D. Notify coding staff to assign the most conservative code
Answer: A
Explanation: Recognizing the chain of command for unresolved queries involves escalating the issue to
the CDI manager or higher leadership when physicians do not respond after reasonable attempts. Directly
contacting department chairs may be premature if appropriate escalation is established. Documenting
non-response without escalation risks incomplete or inaccurate documentation. Coders assigning
conservative codes without physician clarification could affect reimbursement accuracy.
Question: 581
A 65-year-old patient is admitted with chest pain and suspected myocardial infarction. The physician
documents "chest pain, rule out MI" but includes no further details. The CDI practitioner needs to clarify
the diagnosis to ensure accurate coding and reimbursement. Which query format complies with AHIMA's
best practices for a compliant, non-leading query?
A. Please document "acute myocardial infarction" if applicable.
B. Is the chest pain consistent with acute myocardial infarction?
C. Please confirm if the diagnosis is acute myocardial infarction.
D. Could you clarify if the chest pain is due to acute myocardial infarction or another cause?
Answer: D
Explanation: According to AHIMA practice briefs, a compliant query must be non-leading and provide
multiple reasonable options for the provider to consider. "Could you clarify if the chest pain is due to
acute myocardial infarction or another cause?" allows the provider to specify the diagnosis without
suggesting a specific condition, aligning with best practices. "Is the chest pain consistent with acute
myocardial infarction?" and "Please confirm if the diagnosis is acute myocardial infarction" are leading
as they focus solely on myocardial infarction. "Please document 'acute myocardial infarction' if
applicable" is overly directive and non-compliant.
Question: 582
A patient's discharge summary states �status post small bowel obstruction� but no current obstruction is
documented during admission. How should the CDI practitioner handle this?
A. Remove bowel obstruction diagnosis from coding.
B. Accept �status post� as current diagnosis.
C. Query the provider to clarify if the bowel obstruction is active or resolved.
D. Query for history of hernia instead.
Answer: C
Explanation: �Status post� indicates resolved condition; querying clarifies active status for coding.
Accepting as current would be inaccurate; removing diagnosis without provider input is inappropriate,
and querying unrelated diagnosis is not helpful.
Question: 583
A patient is admitted with a principal diagnosis of sepsis due to E- coli (ICD-10-CM: A41.51). The
coder assigns DRG 871 (Sepsis with MCC). The CDI practitioner reviews the record and notes a serum
lactate of 4.2 mmol/L (reference <2.0 mmol/L) and hypotension requiring vasopressors. The physician
does not document severe sepsis. What should the CDI practitioner do to ensure accurate DRG
assignment?
A. Accept the current DRG as it reflects the clinical picture.
B. Query the physician to clarify if severe sepsis is present based on lactate and hypotension.
C. Request the coder to change the DRG to 870 (Sepsis with organ dysfunction).
D. Update the record to include severe sepsis without a query.
Answer: B
Explanation: Querying the physician to clarify if severe sepsis is present based on lactate (4.2 mmol/L)
and hypotension requiring vasopressors is necessary to ensure accurate DRG assignment. These clinical
indicators suggest severe sepsis, which could impact the DRG (e.g., ensuring the MCC is captured).
Accepting the current DRG without clarification risks undercoding. Requesting the coder to change the
DRG without a query is non-compliant, as coders cannot interpret clinical indicators without physician
documentation. Updating the record without a query violates AHIMA guidelines, as CDI practitioners
cannot add diagnoses.
Question: 584
A CDI manager is promoting CDI efforts to hospital administration by presenting a project on improving
documentation for pneumonia cases. The project tracks 50 patients with initial DRG 195 (simple
pneumonia, RW 0.7) and post-CDI intervention DRG 193 (pneumonia with MCC, RW 1.2). The average
reimbursement increase is $3,000 per case. Which strategy best demonstrates the project's value to
administration?
A. Highlight the increase in physician query response time
B. Present the reimbursement increase due to DRG shifts
C. Report the reduction in coding errors
D. Show the decrease in patient readmissions
Answer: B
Explanation: Presenting the reimbursement increase due to DRG shifts from simple pneumonia (RW 0.7)
to pneumonia with MCC (RW 1.2), with a $3,000 per case increase, directly demonstrates financial value
to administration. Physician query response time, coding error reduction, and readmission decreases are
important but less directly tied to financial ROI.
Question: 585
A CDI practitioner reviews a chart with a patient admitted for chest pain and elevated troponin of 0.8
ng/mL. The physician documented "chest pain, rule out MI," but no query was issued. The CDI
dashboard shows a 20% missed opportunity rate for acute MI queries. What is the most compliant action
to Boost this metric?
A. Implement a policy requiring queries for all elevated troponin cases
B. Issue a retrospective query for acute MI based on troponin levels
C. Perform a quality audit to identify missed MI query opportunities
D. Train CDI staff to prioritize troponin-based queries
Answer: C
Explanation: A 20% missed opportunity rate for acute MI queries suggests systemic issues in query
practices. Perform a quality audit to identify missed MI query opportunities is the most compliant
approach to analyze why queries are missed and Boost processes. Implement a policy requiring queries
for all elevated troponin cases is non-compliant, as queries must be based on clinical indicators, not
automatic triggers. Issue a retrospective query for acute MI based on troponin levels may be appropriate
but does not address the broader metric issue. Train CDI staff to prioritize troponin-based queries is too
narrow without audit data.
Question: 586
A patient with chronic obstructive pulmonary disease (COPD) is admitted with an acute exacerbation.
The provider documents �COPD exacerbation� but does not specify severity or presence of respiratory
failure. ABGs show pH 7.30 and pCO2 58 mmHg. How should the CDI practitioner proceed?
A. Query provider for documentation of COPD exacerbation severity including any respiratory failure
indicators
B. Accept general COPD exacerbation diagnosis without severity details
C. Assign respiratory failure based on ABG results without provider input
D. Ignore severity documentation as it does not affect coding
Answer: A
Explanation: Queries that ask providers to specify severity, including respiratory failure, improve
documentation quality and coding accuracy. ABG results provide clinical data supporting severity but
require provider confirmation for documentation integrity. Accepting vague documentation or assigning
codes without provider input is inadequate.
Question: 587
A patient is admitted with a potassium level of 6.5 mEq/L (normal 3.5-5.0 mEq/L) and EKG changes.
The physician documents "electrolyte abnormality." To ensure accurate coding, what is the most
compliant query?
A. Is the electrolyte abnormality related to renal failure?
B. Does the patient have hyperkalemia or another condition?
C. Can you clarify if the electrolyte abnormality is hyperkalemia?
D. Please document the electrolyte abnormality as hyperkalemia.
Answer: C
Explanation: "Can you clarify if the electrolyte abnormality is hyperkalemia?" is compliant, as it uses
clinical indicators (potassium 6.5 mEq/L, EKG changes) and allows the provider to confirm or clarify
without leading. "Does the patient have hyperkalemia or another condition?" is less specific. "Is the
electrolyte abnormality related to renal failure?" is irrelevant to the primary diagnosis. "Please document
the electrolyte abnormality as hyperkalemia" is non-compliant.
Question: 588
During query development, what should a CDIP avoid?
A. Providing clinical indicators to support clarification.
B. Phrasing queries that lead the provider to a specific diagnosis or outcome.
C. Referencing relevant documentation in the query.
D. Including a response option of "No additional information available."
Answer: B
Explanation: Queries must be non-leading. The others represent correct compliant practices.
Question: 589
A 58-year-old male is admitted for acute pancreatitis. The physician documents "acute pancreatitis, likely
alcohol-related." Labs show lipase 1200 U/L (reference <160 U/L) and creatinine 2.5 mg/dL (reference
0.6-1.2 mg/dL). The CDI practitioner notes the elevated creatinine. Which query best clarifies the
documentation for accurate coding?
A. Can you confirm if the pancreatitis is uncomplicated?
B. Does the creatinine of 2.5 mg/dL indicate acute kidney injury?
C. Is the pancreatitis due to gallstones or alcohol?
D. Please document the etiology of the pancreatitis.
Answer: B
Explanation: The query "Does the creatinine of 2.5 mg/dL indicate acute kidney injury?" is most
appropriate as it addresses the elevated creatinine, a clinical indicator of potential acute kidney injury
(AKI), which could qualify as a CC and impact the DRG. It is non-leading and evidence-based. "Can you
confirm if the pancreatitis is uncomplicated?" ignores the creatinine elevation. "Is the pancreatitis due to
gallstones or alcohol?" focuses on etiology without addressing the potential AKI. "Please document the
etiology of the pancreatitis" is too broad and misses the opportunity to capture the CC.
Question: 590
A CDI team collaborates with a physician champion to Boost documentation for acute kidney injury
(AKI). Which initiative best supports AHIMA's leadership development goals?
A. Automate AKI alerts in the EHR
B. Mandate AKI training for CDI staff only
C. Develop an AKI documentation tip sheet with physician input
D. Require daily AKI audits by HIM
Answer: C
Explanation: AHIMA emphasizes physician collaboration in CDI initiatives. Developing an AKI
documentation tip sheet with physician input fosters engagement and aligns with leadership goals.
"Automate AKI alerts in the EHR" lacks physician collaboration. "Mandate AKI training for CDI staff
only" excludes physicians. "Require daily AKI audits by HIM" is not collaborative.
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