AHIMA Certified Documentation Integrity Practitioner Sample Questions:

1. An otherwise healthy male was admitted to undergo a total hip replacement as treatment for ongoing primary osteoarthritis of the right hip. During the post-operative period, the patient choked on liquids which resulted in aspiration pneumonia as shown on chest x-ray.
Intravenous antibiotics were administered, and the pneumonia was
monitored for improvement with two additional chest x-rays. The patient was discharged to home in stable condition on post-operative day 5.
Final Diagnoses:
1. Primary osteoarthritis of right hip status post uncomplicated total hip replacement
2. Aspiration pneumonia due to choking on liquid episode
What is the correct diagnostic related group assignment?

A) 470 Major Joint Replacement or Reattachment of Lower Extremity without MCC
B) 179 Respiratory Infections and Inflammations without CC/MCC
C) 469 Major Joint Replacement or Reattachment of Lower Extremity with MCC
D) 553 Bone Diseases and Arthropathies with MCC

2. An 80-year-old male is admitted as an inpatient to the ICU with shortness of breath, productive yellow sputum, and a temperature of 101.2. CXR reveals bilateral pleural effusion and LLL pneumonia. Labs reveal a BUN of 42 and a creatinine level of 1.500.
The patient is given Zithromax 500 mg. IV, NS IV, and Lasix 40 mg tabs 2x/day. The attending physician documents bilateral pleural effusion, LLL pneumonia, and kidney failure. Two days later, the renal consult documents AKI with acute tubular necrosis (ATN). The correct principal and secondary diagnoses are

A) PDx: AKI with ATN
SDx: LLL pneumonia, bilateral pleural effusion
B) PDx: LLL pneumonia
SDx: Bilateral pleural effusion, kidney failure
C) PDx: Bilateral pleural effusion
SDx: LLL pneumonia, kidney failure
D) PDx: LLL pneumonia
SDx: AKI with ATN, bilateral pleural effusion

3. A 94-year-old female patient is admitted with altered mental status and inability to move the left side of her body. She is diagnosed with a cerebral vascular accident with left sided weakness. The patient is ambidextrous, but the physician does not specify the predominance of the affected side. The default code is

A) ambidextrous
B) dominant
C) non-dominant
D) preferred

4. The correct coding for heart failure with preserved ejection fraction is

A) I50.30 Unspecified diastolic (congestive) heart failure
B) 150.32 Chronic diastolic (congestive) heart failure
C) I50.20 Unspecified systolic (congestive) heart failure
D) I50.9 Heart failure, unspecified

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

Solutions: