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AHIMA Certified Documentation Integrity Practitioner Sample Questions:

1. Which physician would best benefit from additional education for unanswered queries?

A) Dr. A
B) Dr. B
C) Dr. C
D) Dr. D

2. The best approach in resolving unanswered queries is to

A) review the facility's query policies and procedures
B) notify the physician advisor/champion that the physician has not responded to the query
C) contact the physician repeatedly until he/she responds to the query
D) notify the coding team of the physician's unanswered query

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

4. A patient falls off a ladder and undergoes a right femur procedure. Three weeks later, the patient returns to the hospital for removal of the external fixation device. The ICD-10-CM 7th character code value should indicate

A) subsequent
B) initial
C) sequela
D) aftercare

5. Whether or not queries should be kept as a permanent part of the medical record is decided by

A) physician preference
B) state law
C) organizational policy
D) federal law

Solutions: