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AHIMA Certified Documentation Integrity Practitioner Sample Questions:

1. For inpatients with a discharge principal diagnosis of acute myocardial infarction, aspirin must be taken within
24 hours of arrival unless a contraindication to aspirin is
documented. How should this be documented in the health record?

A) The name of the medication (aspirin), the date and location where it was last administered
B) The name of the medication (aspirin) and the date it was last administered
C) The name of the medication (aspirin), the date and time it was last administered
D) The name of the medication (aspirin), the date, time and location where it was last administered

2. When writing a compliant query, best practice is to

A) use a yes/no query format for specificity of a diagnosis
B) include all relevant clinical indicators
C) use the term "possible" to describe a condition or diagnosis when uncertain if the diagnosis is present
D) direct the physician to a specific diagnosis

3. The clinical documentation integrity (CDI) team in a hospital is initiating a project to change the unacceptable documentation behaviors of some physicians. What strategy should be part of a project aimed at improving these behaviors?

A) Add a physician advisor/champion to the CDI team
B) Encourage physician-nurse cooperation
C) Expand use of coding queries by CDI team
D) Alter the physician documentation requirements

4. Which of the following is nonessential to facilitate code capture when educating clinical staff on documentation practices associated with diabetes mellitus?

A) Age
B) Manifestation
C) Cause
D) Type

5. 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) 02HV33Z Insertion of infusion device into superior vena cava, percutaneous approach
B) 05HP33Z Insertion of infusion device into right external jugular vein, percutaneous approach
C) 05HM33Z Insertion of infusion device into right internal jugular vein, percutaneous approach
D) 02H633Z Insertion of infusion device into right atrium, percutaneous approach

Solutions: