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AHIMA Certified Documentation Integrity Practitioner Sample Questions:

1. A 50-year-old male patient was admitted with complaint of 3-day history of shortness of breath. Vital signs:
BP 165/90, P 90, T 99.9.F, O2 sat 95% on room air. Patient
has history of asthma, chronic obstructive pulmonary disease (COPD), and hypertension (HTN). His medicines are Albuterol and Norvasc. CXR showed chronic lung disease and left lower lobe infiltrate. Labs: WBC 9.5 with 65% segs. Physician documented that patient has asthma flair and admitted with decompensated COPD, ordered IV steroids, O2 at 2L/min via nasal cannula, Albuterol inhalers 4x per day, and Clindamycin. Patient improved and was discharged 3 days later. Which action would have the highest impact on the patient's severity of illness (SOI) and risk of mortality (ROM)?

A) Query the physician to clarify for type of COPD such as severe asthma.
B) Query the physician to clarify if patient has acute COPD exacerbation.
C) Query the physician to clarify if CXR result means patient has pneumonia.
D) Query the physician to clarify for clinical significance of the CXR results.

2. A physician documented the specific site of the malignancy in the medical record documentation; however, the coder is unable to locate a specific entry in the ICD-10- CM Alphabetical Index to match the specified diagnosis. Which abbreviation used in the Alphabetical Index will assist the coder in assigning the appropriate diagnosis code for the specified condition?

A) OCE
B) NOS
C) NEC
D) DRG

3. Reviewing and analyzing physician query content on a regular basis

A) helps to calculate query response rate
B) facilitates physician data collection
C) aids in discussion between physician and reviewer
D) assists in identifying gaps in skills and knowledge

4. A patient was admitted for high fever and pain in umbilical region. During the second day of the hospital stay, the patient stood up to use the restroom and fell on the floor, resulting in a broken chin bone. A physician noted the fall on the second day in progress note. Which further clarification should be done regarding present on admission (POA) indicator of fall?

A) Take the case to physician advisor/champion to discuss further action
B) Bring this case up in weekly Health Information Management meetings for further action
C) Query physician for POA
D) No query is needed

5. A noncompliant query includes querying the provider regarding

A) sepsis that was present on admission because sepsis was only documented in the discharge summary
B) morbid obesity due to BMI of 40.9 documented on the history and physical
C) gram-negative pneumonia on every pneumonia case, regardless of documented clinical indicators
D) acute blood loss anemia due to low hemoglobin treated with iron supplements

Solutions: