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AHIMA Certified Documentation Integrity Practitioner Sample Questions:

1. The correct coding for insertion of a dialysis catheter into the right internal jugular vein with the tip ending in the cavoatrial junction is

A) 02H633Z Insertion of infusion device into right atrium, percutaneous approach
B) 05HM33Z Insertion of infusion device into right internal jugular vein, percutaneous approach
C) 02HV33Z Insertion of infusion device into superior vena cava, percutaneous approach
D) 05HP33Z Insertion of infusion device into right external jugular vein, percutaneous approach

2. An otherwise healthy male was admitted to undergo a total hip replacement as treatment for ongoing primary osteoarthritis of the right hip. During the post-operative period, the patient choked on liquids which resulted in aspiration pneumonia as shown on chest x-ray.
Intravenous antibiotics were administered, and the pneumonia was
monitored for improvement with two additional chest x-rays. The patient was discharged to home in stable condition on post-operative day 5.
Final Diagnoses:
1. Primary osteoarthritis of right hip status post uncomplicated total hip replacement
2. Aspiration pneumonia due to choking on liquid episode
What is the correct diagnostic related group assignment?

A) 553 Bone Diseases and Arthropathies with MCC
B) 179 Respiratory Infections and Inflammations without CC/MCC
C) 470 Major Joint Replacement or Reattachment of Lower Extremity without MCC
D) 469 Major Joint Replacement or Reattachment of Lower Extremity with MCC

3. An 80-year-old male is admitted as an inpatient to the ICU with shortness of breath, productive yellow sputum, and a temperature of 101.2. CXR reveals bilateral pleural effusion and LLL pneumonia. Labs reveal a BUN of 42 and a creatinine level of 1.500.
The patient is given Zithromax 500 mg. IV, NS IV, and Lasix 40 mg tabs 2x/day. The attending physician documents bilateral pleural effusion, LLL pneumonia, and kidney failure. Two days later, the renal consult documents AKI with acute tubular necrosis (ATN). The correct principal and secondary diagnoses are

A) PDx: AKI with ATN
SDx: LLL pneumonia, bilateral pleural effusion
B) PDx: LLL pneumonia
SDx: Bilateral pleural effusion, kidney failure
C) PDx: Bilateral pleural effusion
SDx: LLL pneumonia, kidney failure
D) PDx: LLL pneumonia
SDx: AKI with ATN, bilateral pleural effusion

4. Which of the following may result in an incomplete health record deficiency being assigned to a provider?

A) A quality query
B) An outstanding query
C) A concurrent query
D) A retrospective query

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

Solutions: