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AHIMA Certified Documentation Integrity Practitioner Sample Questions:

1. Which of the following is the definition of an Excludes 2 note in ICD-10-CM?

A) Neither of the codes can be assigned
B) This is not a convention found in ICD-10-CM
C) Only one code can be assigned to completely describe the condition
D) Two codes can be used together to completely describe the condition

2. The clinical documentation integrity (CDI) manager reviewed all payer refined-diagnosis related groups (APR-DRG) benchmarking data and has identified potential opportunities for improvement. The manager hopes to develop a work plan to target severity of illness (SOI)/risk of mortality (ROM) by service line and providers. How can the manager gain more information about this situation?

A) Audit focused APR-DRGs and develop education plan for CDI team and physicians
B) Audit cases for missed diagnosis by the CDI practitioner to target in the education plan
C) Audit focused cases by physicians that have a higher SOI/ROM for education plan
D) Audit cases that have high SOI/ROM assigned by coders for education and follow-up

3. Given the following ICD-10-CM Alphabetical Index entry:
Ectopic (pregnancy) 008.9
What is the meaning of the parenthesis?

A) Non-essential modifiers
B) Exclusion notes
C) Essential modifiers
D) Inclusion notes

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

Solutions: