CERTIFIED DOCUMENTATION INTEGRITY
PRACTITIONER (CDIP) EXAM
Diabetes is a condition that exists when glucose (blood sugar) levels are above the
normal range. Which of the following drugs are treatments for diabetes?
a.Amaryl
b.Metformin
c.Avandia
d.a and b only
e.b and c
f.a, b, and c - ANSWERS-f Amaryl (glimepiride) second generation sulfonylureas,
Metformin (glucophage) and Avandia (rosiglitazone) decrease the amount of
glucose produced by the liver (AHIMA 2015).
Drug therapies for heart disease treatment include:
a.Vasodilators
b.Beta blockers
c.Calcium channel blockers
d.Both a and b
e.a, b, and c - ANSWERS-e It is important that you can identify medications as
there may be treatment performed with unclear documentation and the need to
,query for certain conditions, if there is clinical indications and treatment (AHIMA
2015; Heart.org 2015).
A 18 year-old male was admitted with exacerbation of asthma. To assign this
diagnosis for coding, the diagnosis should be clarified for:
a.Mild persistent
b.Persistent persistent
c.Moderate persistent
d.Unspecified
e.All of the above - ANSWERS-e All of the diagnoses listed could further describe
the state of the patient's asthma. (CMS 2016b)
When a pregnant patient presents for a condition, it is important to determine:
a.If the condition of the mother that existed prior to pregnancy (pre-existing).
b.If the condition developed during or is due to the pregnancy.
c.If no additional information is needed for appropriate diagnosis selection.
d.Both a and b - ANSWERS-d Pre-existing conditions versus conditions due to the
pregnancy Certain categories in Chapter 15 distinguish between conditions of the
mother that existed prior to pregnancy (pre-existing) and those that are a direct
result of pregnancy. When assigning codes from Chapter 15, it is important to
assess if a condition was pre-existing prior to pregnancy or developed during or
due to the pregnancy in order to assign the correct code. Categories that do not
distinguish between pre-existing and pregnancy related conditions may be used
for either. It is acceptable to use codes specifically for the puerperium with codes
complicating pregnancy and childbirth if a condition arises postpartum during the
delivery encounter (CMS 2016b).
,The CDS review specialist has been performing CDI review on the first day of
admission. What impact could this have on the review process?
a.None
b.Provides the opportunity to capture POA diagnoses
c.Can provide little positive impact due to clinical documentation is normally
incomplete on the first day.
d.Gives the CDS the opportunity for the CDS to add the physician in building the
documentation - ANSWERS-c The CDI staff 's concurrent record review should
begin on the second day after admission. Clinical documentation is normally
incomplete on the first day. Review of the record at that time would have little
benefit. The CDI manager should consider weekend and holiday coverage (Hess
2015, 176).
An organization should have a query policy and procedure to:
a.Learn how to write queries.
b.Outline the physician's responsibility in responding to queries.
c.Assist in the CDS hiring process.
d.Outline the components of the medical record. - ANSWERS-b Every organization
should develop a query policy and procedure that is specific to its organization
and that addresses
•When to ask queries
•Who asks queries and to whom
•The hospital's responsibility in supporting the query process
•The physician's responsibility in responding to queries
, •Acceptable ways to respond to queries
A set of indicators providing information on potential in hospital complications
and adverse events following surgeries, procedures, and childbirth:
a.Core measures
b.Healthcare Effectiveness Data and Information Set (HEDIS)
c.Physician Quality Reporting System (PQRS)
d.Patient Safety Indicators (PSI) - ANSWERS-d The Patient Safety Indicators (PSIs)
are a set of indicators providing information on potential in hospital complications
and adverse events following surgeries, procedures, and childbirth. The PSIs were
developed after a comprehensive literature review, analysis of ICD-10-CM codes,
review by a clinician panel, implementation of risk adjustment, and empirical
analyses (AHIMA 2015; AHRQ 2015).
For PSI (Patient Safety Indicators) 11: Postoperative respiratory failure
documentation may require query to improve documentation for:
a.The reason for prolonged intubation when noted.
b.Disregarding this PSI
c.Intubation noted to exist anytime following surgery.
d.None of the above - ANSWERS-a As published by the AHRQ (Agency on
Healthcare Research and Quality) toolkit, PSI 11: Postoperative respiratory failure
Avoid using coding for intubation as it is an expected part of a procedure. Improve
documentation of the reasons for reintubation or prolonged ventilation. Three
clinical issues that were identified during the project potentially warrant further
attention. There were two cases of oversedation leading to respiratory
complications; some patients likely could have been extubated earlier, which
PRACTITIONER (CDIP) EXAM
Diabetes is a condition that exists when glucose (blood sugar) levels are above the
normal range. Which of the following drugs are treatments for diabetes?
a.Amaryl
b.Metformin
c.Avandia
d.a and b only
e.b and c
f.a, b, and c - ANSWERS-f Amaryl (glimepiride) second generation sulfonylureas,
Metformin (glucophage) and Avandia (rosiglitazone) decrease the amount of
glucose produced by the liver (AHIMA 2015).
Drug therapies for heart disease treatment include:
a.Vasodilators
b.Beta blockers
c.Calcium channel blockers
d.Both a and b
e.a, b, and c - ANSWERS-e It is important that you can identify medications as
there may be treatment performed with unclear documentation and the need to
,query for certain conditions, if there is clinical indications and treatment (AHIMA
2015; Heart.org 2015).
A 18 year-old male was admitted with exacerbation of asthma. To assign this
diagnosis for coding, the diagnosis should be clarified for:
a.Mild persistent
b.Persistent persistent
c.Moderate persistent
d.Unspecified
e.All of the above - ANSWERS-e All of the diagnoses listed could further describe
the state of the patient's asthma. (CMS 2016b)
When a pregnant patient presents for a condition, it is important to determine:
a.If the condition of the mother that existed prior to pregnancy (pre-existing).
b.If the condition developed during or is due to the pregnancy.
c.If no additional information is needed for appropriate diagnosis selection.
d.Both a and b - ANSWERS-d Pre-existing conditions versus conditions due to the
pregnancy Certain categories in Chapter 15 distinguish between conditions of the
mother that existed prior to pregnancy (pre-existing) and those that are a direct
result of pregnancy. When assigning codes from Chapter 15, it is important to
assess if a condition was pre-existing prior to pregnancy or developed during or
due to the pregnancy in order to assign the correct code. Categories that do not
distinguish between pre-existing and pregnancy related conditions may be used
for either. It is acceptable to use codes specifically for the puerperium with codes
complicating pregnancy and childbirth if a condition arises postpartum during the
delivery encounter (CMS 2016b).
,The CDS review specialist has been performing CDI review on the first day of
admission. What impact could this have on the review process?
a.None
b.Provides the opportunity to capture POA diagnoses
c.Can provide little positive impact due to clinical documentation is normally
incomplete on the first day.
d.Gives the CDS the opportunity for the CDS to add the physician in building the
documentation - ANSWERS-c The CDI staff 's concurrent record review should
begin on the second day after admission. Clinical documentation is normally
incomplete on the first day. Review of the record at that time would have little
benefit. The CDI manager should consider weekend and holiday coverage (Hess
2015, 176).
An organization should have a query policy and procedure to:
a.Learn how to write queries.
b.Outline the physician's responsibility in responding to queries.
c.Assist in the CDS hiring process.
d.Outline the components of the medical record. - ANSWERS-b Every organization
should develop a query policy and procedure that is specific to its organization
and that addresses
•When to ask queries
•Who asks queries and to whom
•The hospital's responsibility in supporting the query process
•The physician's responsibility in responding to queries
, •Acceptable ways to respond to queries
A set of indicators providing information on potential in hospital complications
and adverse events following surgeries, procedures, and childbirth:
a.Core measures
b.Healthcare Effectiveness Data and Information Set (HEDIS)
c.Physician Quality Reporting System (PQRS)
d.Patient Safety Indicators (PSI) - ANSWERS-d The Patient Safety Indicators (PSIs)
are a set of indicators providing information on potential in hospital complications
and adverse events following surgeries, procedures, and childbirth. The PSIs were
developed after a comprehensive literature review, analysis of ICD-10-CM codes,
review by a clinician panel, implementation of risk adjustment, and empirical
analyses (AHIMA 2015; AHRQ 2015).
For PSI (Patient Safety Indicators) 11: Postoperative respiratory failure
documentation may require query to improve documentation for:
a.The reason for prolonged intubation when noted.
b.Disregarding this PSI
c.Intubation noted to exist anytime following surgery.
d.None of the above - ANSWERS-a As published by the AHRQ (Agency on
Healthcare Research and Quality) toolkit, PSI 11: Postoperative respiratory failure
Avoid using coding for intubation as it is an expected part of a procedure. Improve
documentation of the reasons for reintubation or prolonged ventilation. Three
clinical issues that were identified during the project potentially warrant further
attention. There were two cases of oversedation leading to respiratory
complications; some patients likely could have been extubated earlier, which
