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AHIMA Certified Documentation Integrity Practitioner Sample Questions:

1. A 100-year-old female presents to the emergency department with altered mental state and a 3-day history of productive cough, shortness of breath, and fever after a witnessed aspiration 3 days ago. The patient lives in custodial care at a nearby skilled nursing facility. Patient was treated with Augmentin at the facility without improvement. Exam is notable for Tc 38.9, blood pressure 142/78, respiratory rate 28, pulse 91. There is accessory muscle use with breathing.
Patient is moaning and disoriented but
otherwise the neurologic exam is nonfocal.
Labs notable for sodium 126, creatinine 0.5. white blood count 17.5, hemoglobin 13, platelet 200. venous blood gas 7.44/32/45/-3 Chest x-ray shows bilateral lower lobe infiltrates and dense right lower lobe consolidation.
Patient is placed on bilevel positive airway pressure and given vancomycin, pip/tazo, levofloxacin.
Discharge Diagnosis: health care associated pneumonia (HCAP), respiratory distress, altered mental status, low sodium Which list of diagnoses require a post-discharge query that will result in a more specific principal diagnosis with the highest level of severity of illness and risk of mortality?

A) Aspiration pneumonia, hyponatremia, septic encephalopathy, and sepsis with acute hypoxemic respiratory failure
B) Sepsis with acute hypoxemic respiratory failure, hyponatremia, pneumonia
C) Severe sepsis, hypernatremia, delirium, pneumonia
D) Coma, stroke, HCAP, hypernatremia

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

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

3. A 50-year-old with a history of stage II lung cancer is brought to the emergency department with severe dyspnea. The patient underwent the last round of chemotherapy
3 days ago. Vital signs reveal a temperature of 98.4, a heart rate of 98, a respiratory rate of 28, and a blood pressure of 124/82. O2 saturation on room air is 92%. The patient is 5'5"and weighs 98 lbs. The registered dietitian notes the patient is malnourished with BMI of 19.
Chest x-ray reveals a large pleural effusion in the right lung.
Thoracentesis is performed and 1000 cc serosanguinous fluid is removed. The admitting diagnosis is large right lung pleural effusion related to lung cancer stage II, documented multiple times. What post discharge query opportunity should be sent to the physician that will affect severity of illness (SOI)/risk of mortality (ROM)?

A) Query for malignant pleural effusion
B) Query for protein calorie malnutrition
C) Query for a diagnosis associated with the dietician's finding of malnutrition
D) Query if the malignant pleural effusion is the reason for admission

4. Tracking denials within the clinical documentation integrity program is important to

A) confirm reimbursement was appropriate
B) file a timely appeal if the medical center disagrees with the RAC findings
C) identify documentation improvement opportunities and educate as necessary
D) determine coding inaccuracies and educate as necessary

5. A noncompliant query includes querying the provider regarding

A) acute blood loss anemia due to low hemoglobin treated with iron supplements
B) gram-negative pneumonia on every pneumonia case, regardless of documented clinical indicators
C) sepsis that was present on admission because sepsis was only documented in the discharge summary
D) morbid obesity due to BMI of 40.9 documented on the history and physical

Solutions: