AHIMA Certified Documentation Integrity Practitioner Sample Questions:

1. 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) 61154 Burr hole(s) with evacuation and/or drainage of hematoma, extradural or subdural
B) 61105 Twist drill hole subdural/ventricular puncture
C) 61108 Twist drill hole(s) for subdural, intracerebral, or ventricular puncture; for evacuation and/or drainage of subdural hematoma
D) 61140 Burr hole(s) or trephine; with biopsy of brain or intracranial lesion

2. Which of the following is a clinical documentation integrity (CDI) financial impact measure?

A) Severity of illness
B) Release of information
C) Case mix index
D) Hierarchical condition category

3. A 75-year-old, diabetic patient with a history of osteoporosis, being treated with Fosamax, who sustained a femur fracture after falling down three stairs. The provider's documentation indicates to admit the patient for a traumatic femur fracture and an orthopedics consult is pending. The clinical documentation integrity practitioner (CDIP) decides to query for a possible link between osteoporosis and the femur fracture. Which of the following is the most compliant query based on the most recent AHIMA/ACDIS query practice brief?

A) Patient admitted for a femur fracture with a history of osteoporosis being treated with Fosamax. Please clarify the cause of the femur fracture in your next note and/or the discharge summary.
B) Patient admitted for a femur fracture with a history of osteoporosis being treated with Fosamax. Could diabetes be a contributing factor in the femur fracture?
C) Patient admitted for a femur fracture with a history of osteoporosis being treated with Fosamax. Please document "femur fracture due to osteoporosis" in your next progress note to demonstrate a link between the two diagnoses.
D) Patient admitted for a femur fracture with a history of osteoporosis being treated with Fosamax. In your medical opinion, is this fracture consistent with an osteoporotic pathological fracture?

4. What type of query may NOT be used in circumstances where only clinical indicators of a condition are present, and the condition/diagnosis has not been documented in the health record?

A) Multiple-choice
B) Open-ended
C) Yes/No
D) Verbal

5. A resident returns to the long-term care facility following hospital care for pneumonia. The physician's orders and progress note state "Continue IV antibiotics for pneumonia - 3 more days, after which time the resident is to have a repeat x-ray to determine status of the pneumonia". Is it appropriate to code the pneumonia in this scenario?

A) No, since the patient needed a repeat x-ray, the condition does not clarify as a diagnosis
B) Yes J18.8, Pneumonia, other specified organism
C) Yes, J18.9, Pneumonia, unspecified organism, Z79.2 should be coded along with long term antibiotics
D) Yes, J18.9, Pneumonia, unspecified organism, should be coded until the condition is resolved

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