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AHIMA CDIP Exam Syllabus Topics:

AHIMA Certified Documentation Integrity Practitioner Sample Questions:

1. A patient presented with shortness of breath, elevated B-type natriuretic peptide, and lower extremity edema to the emergency room. During the hospitalization, a cardiac echocardiogram was performed and revealed an ejection fraction of 55% with diastolic dysfunction. The patient's history includes hypertension (HTN), chronic kidney disease (CKD) (baseline glomerular filtration rate 40) and congestive heart failure (CHF). The clinical documentation integrity practitioner (CDIP) has queried the physician to further clarify the patient's diagnosis. Which response provides the highest level of specificity?

A) Acute on chronic diastolic CHF with hypertensive renal disease, CKD 3
B) Acute diastolic CHF with HTN and CKD 3
C) Acute CHF with hypertensive renal disease, CKD 3
D) Acute on chronic systolic CHF with hypertensive renal disease, CKD 3

2. A 75-year-old, diabetic patient with a history of osteoporosis, being treated with Fosamax, who sustained a femur fracture after falling down three stairs. The provider's documentation indicates to admit the patient for a traumatic femur fracture and an orthopedics consult is pending. The clinical documentation integrity practitioner (CDIP) decides to query for a possible link between osteoporosis and the femur fracture. Which of the following is the most compliant query based on the most recent AHIMA/ACDIS query practice brief?

A) Patient admitted for a femur fracture with a history of osteoporosis being treated with Fosamax. In your medical opinion, is this fracture consistent with an osteoporotic pathological fracture?
B) Patient admitted for a femur fracture with a history of osteoporosis being treated with Fosamax. Please document "femur fracture due to osteoporosis" in your next progress note to demonstrate a link between the two diagnoses.
C) Patient admitted for a femur fracture with a history of osteoporosis being treated with Fosamax. Please clarify the cause of the femur fracture in your next note and/or the discharge summary.
D) Patient admitted for a femur fracture with a history of osteoporosis being treated with Fosamax. Could diabetes be a contributing factor in the femur fracture?

3. A 77-year-old male with chronic obstructive pulmonary disease (COPD) is admitted as an inpatient with severe shortness of breath. The patient is placed on oxygen at 2 liters per minute via nasal cannula. History reveals that the patient is on oxygen nightly at home. CXR is unremarkable. The most compliant query is

A) Patient has COPD, and is on nocturnal oxygen at home and is on continuous oxygen since admission.
Please order further tests so the patient's severity of illness can be captured with the most accurate coding assignment.
B) Patient has COPD and is on oxygen every night at home and has been on continuous oxygen since admission. Based on these indications, please document chronic respiratory failure, acute respiratory failure, acute on chronic respiratory failure.
C) Patient has COPD, and is on nocturnal oxygen at home and is on continuous oxygen since admission.
Please indicate if you are treating one of these diagnoses: chronic respiratory failure, acute respiratory failure, acute on chronic respiratory failure, unable to determine, other.
D) Patient has COPD and is on oxygen every night at home and has been on continuous oxygen since admission, please document chronic respiratory failure, hypoxia, acute on chronic respiratory failure.

4. The correct coding for heart failure with preserved ejection fraction is

A) I50.9 Heart failure, unspecified
B) 150.32 Chronic diastolic (congestive) heart failure
C) I50.30 Unspecified diastolic (congestive) heart failure
D) I50.20 Unspecified systolic (congestive) heart failure

5. A query should be generated when the documentation is

A) conflicting
B) legible
C) consistent
D) complete

Solutions: