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AHIMA Certified Documentation Integrity Practitioner Sample Questions:

1. A patient is admitted for pneumonia with a WBC of 20,000, respiratory rate 20, heart rate 85, and oral temperature 99.0°. On day 2, sputum cultures reveal positive results for pseudomonas bacteria. The most appropriate action is to

A) code pneumonia, unspecified
B) code pseudomonas pneumonia
C) query the provider to document the etiology of pneumonia
D) query the provider to see if pseudomonas sepsis is supported by the health record

2. A hospital administrator has hired a clinical documentation integrity (CDI) firm to improve its revenue objectives. The physicians object to this action. How should the firm collaborate with physicians to overcome their objections?

A) Identify an influential physician advisor/champion to promote support
B) Communicate the benefits of the CDI firm about the project
C) Hire a consultant to communicate the benefits to the physicians
D) Create a vision statement that outlines the project objectives

3. What type of laboratory test is a creatinine test?

A) Serology
B) Chemistry
C) Hematology
D) Microbiology

4. Which of the following demonstrates the relative severity and complexity of patient treated in the hospital, and is used to evaluate the financial impact of a hospital's clinical documentation integrity (CDI) program?

A) Hospital acquired conditions
B) Adjusted case mix index
C) Program for evaluating payment patterns electronic report
D) Present on admission indicators

5. 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) 61105 Twist drill hole subdural/ventricular puncture
B) 61140 Burr hole(s) or trephine; with biopsy of brain or intracranial lesion
C) 61108 Twist drill hole(s) for subdural, intracerebral, or ventricular puncture; for evacuation and/or drainage of subdural hematoma
D) 61154 Burr hole(s) with evacuation and/or drainage of hematoma, extradural or subdural

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