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AHIMA Certified Documentation Integrity Practitioner Sample Questions:

1. The clinical documentation integrity (CDI) manager is meeting with a steering committee to discuss the adoption of a new CDI program. The plan is to use case mix index (CMI) as a metric of CDI performance.
How will this metric be measured?

A) Month-to-month to show CMI variability as a barometer of a specific month
B) Over time with a focus on high relative weight (RW) procedures that impact these procedures on overall CMI
C) Over time with a focus on particular documentation improvement areas in addition to the overall CMI
D) Month-to-month and focus on patient volumes to determine the raise the overall CMI

2. The clinical documentation integrity practitioner (CDIP) is reviewing tracking data and has noted physician responses are not captured in the medical chart. What can be done to improve this process?

A) Require the CDIP to call physicians to follow up
B) Allow physician responses via e-mail
C) Update medical records with unsigned physician responses
D) Provide education to physicians on query process

3. A patient presents to the emergency department for evaluation after suffering a head injury during a fall. A traumatic subdural hematoma is found on MRI, and the patient is taken directly to the operating room for evacuation. The neurosurgeon performs a burr hole procedure for evacuation of the subdural hematoma. The clot is removed successfully, and the patient is transferred to recovery in stable condition. Which is the correct current procedural terminology (CPT) code assignment for the procedure performed?

A) 61140 Burr hole(s) or trephine; with biopsy of brain or intracranial lesion
B) 61154 Burr hole(s) with evacuation and/or drainage of hematoma, extradural or subdural
C) 61105 Twist drill hole subdural/ventricular puncture
D) 61108 Twist drill hole(s) for subdural, intracerebral, or ventricular puncture; for evacuation and/or drainage of subdural hematoma

4. A clinical documentation integrity practitioner (CDIP) is reviewing an outpatient surgical chart. The patient underwent a laparoscopic appendectomy for acute gangrenous appendicitis. Which coding reference should be used for coding advice on correct assignment of the procedure code for proper ambulatory payment classification (APC) reimbursement?

A) O AMA CPT Assistant
B) The Merck Manual
C) O ICD-10-CM/PCS Codebook
D) AHA Coding Clinic for ICD-10-CM/PCS

5. The BEST place for the provider to document a query response is which of the following?

A) An addendum to the history and physical
B) The next progress note and all subsequent notes including the discharge summary
C) The next progress note and the problem list
D) The query form

Solutions: