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

2. Which of the following demonstrates the relative severity and complexity of patient treated in the hospital, and is used to evaluate the financial impact of a hospital's clinical documentation integrity (CDI) program?

A) Hospital acquired conditions
B) Program for evaluating payment patterns electronic report
C) Present on admission indicators
D) Adjusted case mix index

3. A 100-year-old female presents to the emergency department with altered mental state and a 3-day history of productive cough, shortness of breath, and fever after a witnessed aspiration 3 days ago. The patient lives in custodial care at a nearby skilled nursing facility. Patient was treated with Augmentin at the facility without improvement. Exam is notable for Tc 38.9, blood pressure 142/78, respiratory rate 28, pulse 91. There is accessory muscle use with breathing.
Patient is moaning and disoriented but
otherwise the neurologic exam is nonfocal.
Labs notable for sodium 126, creatinine 0.5. white blood count 17.5, hemoglobin 13, platelet 200. venous blood gas 7.44/32/45/-3 Chest x-ray shows bilateral lower lobe infiltrates and dense right lower lobe consolidation.
Patient is placed on bilevel positive airway pressure and given vancomycin, pip/tazo, levofloxacin.
Discharge Diagnosis: health care associated pneumonia (HCAP), respiratory distress, altered mental status, low sodium Which list of diagnoses require a post-discharge query that will result in a more specific principal diagnosis with the highest level of severity of illness and risk of mortality?

A) Severe sepsis, hypernatremia, delirium, pneumonia
B) Aspiration pneumonia, hyponatremia, septic encephalopathy, and sepsis with acute hypoxemic respiratory failure
C) Coma, stroke, HCAP, hypernatremia
D) Sepsis with acute hypoxemic respiratory failure, hyponatremia, pneumonia

4. A hospital administrator wants to initiate a clinical documentation integrity (CDI) program and has developed a steering committee to identify performance metrics. The CDI manager expects to use a case mix index as one of the metrics. Which other metric will need to be measured?

A) Comparison of risk of mortality with diagnostic related group capture rates
B) Assessment of CC/MCC capture rates
C) Comparison of severity of illness with the CC capture rates
D) Assessment of APR-DRGs with capture of CC or MCC

5. The facility has received a clinical validation denial for sepsis. The denial states sepsis is not a clinically valid diagnosis because it does not meet Sepsis-3 criteria. The facility has a policy stating it uses Sepsis-2 criteria.
What is the BEST next step?

A) Appeal the denial because all payors must use the hospital's sepsis criteria when reviewing their claims.
B) Have the contracting department work with payors to obtain agreement on how sepsis will be clinically validated.
C) Query physicians when Sepsis-3 criteria is not met so they can provide additional documentation to support the diagnosis.
D) Remove sepsis from all claims where the diagnosis is not supported by sepsis 3 criteria.

Solutions: