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AHIMA Certified Documentation Integrity Practitioner Sample Questions:

1. Which of the following sources provide external benchmarks to examine the effectiveness of a facility's clinical documentation program?

A) American Health Information Management Association
B) Medicare Provider Analysis and Review
C) Agency for Healthcare Research and Quality
D) Health Care Financing Administration

2. The provider was queried because the patient met clinical criteria for acute hypoxic respiratory failure. The response to the query was different than what was expected by the clinical documentation integrity practitioner (CDIP). What should the CDIP do?

A) Record the query response as disagreed
B) Implement the department's escalation process
C) Revise the query and send it back to the provider
D) Have a different CDIP query the provider

3. A clinical documentation integrity practitioner (CDIP) has been successful in getting physicians to respond to queries. However, when the CDIP poses a query to a specific doctor, there is no response at all. The CDIP has tried face-to-face conversations, calling, emails, texts, but still gets no response. What is the next step the CDIP should take?

A) Hold a meeting with the CDI director and the doctor to find out why the doctor is not responding to the queries
B) Elevate the issue to the physician advisor/champion after the CDI supervisor has reviewed the case and deemed the query appropriate
C) Report the doctor to the Vice President of Medical Affairs so the doctor understands the importance of clinical documentation
D) Warn the other CDIPs that the doctor is a non-responder and to forego querying

4. A clinical documentation integrity practitioner (CDIP) hired by an internal medicine clinic is creating policies governing written queries. What is an AHIMA best practice for these policies?

A) Non-responses to written queries are grounds for discipline
B) Queries for illegible chart notes are unnecessary
C) Primary care physicians must answer written queries
D) Queries are limited to non-leading questions

5. A clinical documentation integrity practitioner (CDIP) identified the need to correct a resident physician's note in a patient health record that wrongly identified the organism causing the patient's pneumonia. What is best practice for fixing this mistake according to AHIMA?

A) Coders can rely on the laboratory results to confirm the patient's diagnosis
B) Errors are corrected by the clinician who authored the documentation
C) Amendments to record content must be co-signed by the attending physician
D) Any physician caring for the patient can correct inaccurate record notes

Solutions: