CDIP Certified Documentation Integrity Practitioner Exam:
Questions with Correct Verified Answers & Rationales
(2026/2027 Edition)
SUBTITLE:
60 Exam Questions with Answers & Detailed Rationales
PREPARED FOR:
CDIP Certification Examination - AHIMA
DOCUMENT INCLUDES:
● Exam-style questions
● Correct answers
● Detailed rationales
● Key topics covered
TOPICS COVERED:
● Clinical Coding Practice (ICD-10-CM/PCS, DRG Assignment, Coding Conventions)
● Education and Leadership Development (Provider Education, CDI Collaboration,
Program Influence)
● Record Review & Document Clarification (Query Processes, Clinical Indicators,
Documentation Gaps)
● CDI Metrics & Statistics (Dashboard Metrics, Query Rates, Denial Trends, Quality
Indicators)
● Compliance (Ethical CDI, Regulatory Requirements, Audit Risk, Clinical Validation)
,SECTION 1: CLINICAL CODING PRACTICE
Question 1
A 72-year-old patient is admitted with acute respiratory failure due to aspiration
pneumonia. The patient also has stage 3 chronic kidney disease and type 2 diabetes
mellitus without complications. Which diagnosis should be sequenced as the principal
diagnosis?
A. Acute respiratory failure
B. Aspiration pneumonia
C. Stage 3 chronic kidney disease
D. Type 2 diabetes mellitus
Correct Answer: B
Rationale: According to ICD-10-CM Official Guidelines for Coding and Reporting, the
principal diagnosis is defined as the condition established after study to be chiefly
responsible for occasioning the admission of the patient to the hospital for care. In this
scenario, the aspiration pneumonia is the underlying cause of the acute respiratory
failure. The respiratory failure is a manifestation of the pneumonia, and per guideline
conventions, the underlying condition (aspiration pneumonia) is sequenced first,
followed by the manifestation (acute respiratory failure). Stage 3 CKD and type 2
diabetes are chronic comorbidities that would be coded as secondary diagnoses but do
not represent the principal reason for admission.
,Question 2
A patient undergoes a laparoscopic cholecystectomy with intraoperative
cholangiogram. During the same operative session, the surgeon also performs an
exploratory laparoscopy due to suspected adhesions, which were lysed. How should the
procedure coding be approached?
A. Code only the laparoscopic cholecystectomy
B. Code the cholecystectomy and cholangiogram only; the lysis of adhesions is bundled
C. Code the laparoscopic cholecystectomy, intraoperative cholangiogram, and lysis of
adhesions separately
D. Code the cholecystectomy with a modifier to indicate the additional work
Correct Answer: C
Rationale: In ICD-10-PCS, each distinct procedure performed during the same operative
episode is coded separately when they meet the definition of a separate procedure. The
laparoscopic cholecystectomy (0FT44ZZ), intraoperative cholangiogram (BF14ZZZ),
and lysis of adhesions (0DNW4ZZ) are all distinct procedures with different objectives.
The lysis of adhesions is not inherently bundled into the cholecystectomy unless
performed through the same incision and considered an integral part of access.
Because the surgeon performed an exploratory laparoscopy specifically for adhesions
and lysed them, this represents separate work that should be captured. Modifier usage
is a CPT concept, not an ICD-10-PCS convention.
Question 3
, A patient is admitted with sepsis due to methicillin-susceptible Staphylococcus aureus
(MSSA). Blood cultures confirm MSSA. The patient also has a documented urinary tract
infection due to Escherichia coli. Which coding sequence is correct?
A. A41.01, N39.0
B. A41.9, B96.20, N39.0
C. A41.01, B96.20, N39.0
D. A49.01, N39.0
Correct Answer: A
Rationale: Per ICD-10-CM guidelines, when a patient has sepsis due to a specific
organism, the code for the specific organism (A41.01, Sepsis due to Methicillin
susceptible Staphylococcus aureus) is assigned as the principal diagnosis if it meets
principal diagnosis criteria. The UTI due to E. coli is coded as N39.0 (Urinary tract
infection, site not specified) with B96.20 (Unspecified Escherichia coli [E. coli] as the
cause of diseases classified elsewhere) as an additional code to identify the organism.
However, when sepsis is due to a specific organism, the causal organism code (A41.01)
is used rather than B96.20 for the MSSA. The E. coli causing the UTI would be captured
with B96.20 only if the UTI is not specifically linked to the sepsis pathway. Option A
correctly sequences the sepsis due to MSSA and the UTI.
Question 4
Which of the following statements regarding Present on Admission (POA) indicator
assignment is correct?
A. POA indicators are only required on the principal diagnosis
B. POA "Y" means the condition was present at the time of inpatient admission
Questions with Correct Verified Answers & Rationales
(2026/2027 Edition)
SUBTITLE:
60 Exam Questions with Answers & Detailed Rationales
PREPARED FOR:
CDIP Certification Examination - AHIMA
DOCUMENT INCLUDES:
● Exam-style questions
● Correct answers
● Detailed rationales
● Key topics covered
TOPICS COVERED:
● Clinical Coding Practice (ICD-10-CM/PCS, DRG Assignment, Coding Conventions)
● Education and Leadership Development (Provider Education, CDI Collaboration,
Program Influence)
● Record Review & Document Clarification (Query Processes, Clinical Indicators,
Documentation Gaps)
● CDI Metrics & Statistics (Dashboard Metrics, Query Rates, Denial Trends, Quality
Indicators)
● Compliance (Ethical CDI, Regulatory Requirements, Audit Risk, Clinical Validation)
,SECTION 1: CLINICAL CODING PRACTICE
Question 1
A 72-year-old patient is admitted with acute respiratory failure due to aspiration
pneumonia. The patient also has stage 3 chronic kidney disease and type 2 diabetes
mellitus without complications. Which diagnosis should be sequenced as the principal
diagnosis?
A. Acute respiratory failure
B. Aspiration pneumonia
C. Stage 3 chronic kidney disease
D. Type 2 diabetes mellitus
Correct Answer: B
Rationale: According to ICD-10-CM Official Guidelines for Coding and Reporting, the
principal diagnosis is defined as the condition established after study to be chiefly
responsible for occasioning the admission of the patient to the hospital for care. In this
scenario, the aspiration pneumonia is the underlying cause of the acute respiratory
failure. The respiratory failure is a manifestation of the pneumonia, and per guideline
conventions, the underlying condition (aspiration pneumonia) is sequenced first,
followed by the manifestation (acute respiratory failure). Stage 3 CKD and type 2
diabetes are chronic comorbidities that would be coded as secondary diagnoses but do
not represent the principal reason for admission.
,Question 2
A patient undergoes a laparoscopic cholecystectomy with intraoperative
cholangiogram. During the same operative session, the surgeon also performs an
exploratory laparoscopy due to suspected adhesions, which were lysed. How should the
procedure coding be approached?
A. Code only the laparoscopic cholecystectomy
B. Code the cholecystectomy and cholangiogram only; the lysis of adhesions is bundled
C. Code the laparoscopic cholecystectomy, intraoperative cholangiogram, and lysis of
adhesions separately
D. Code the cholecystectomy with a modifier to indicate the additional work
Correct Answer: C
Rationale: In ICD-10-PCS, each distinct procedure performed during the same operative
episode is coded separately when they meet the definition of a separate procedure. The
laparoscopic cholecystectomy (0FT44ZZ), intraoperative cholangiogram (BF14ZZZ),
and lysis of adhesions (0DNW4ZZ) are all distinct procedures with different objectives.
The lysis of adhesions is not inherently bundled into the cholecystectomy unless
performed through the same incision and considered an integral part of access.
Because the surgeon performed an exploratory laparoscopy specifically for adhesions
and lysed them, this represents separate work that should be captured. Modifier usage
is a CPT concept, not an ICD-10-PCS convention.
Question 3
, A patient is admitted with sepsis due to methicillin-susceptible Staphylococcus aureus
(MSSA). Blood cultures confirm MSSA. The patient also has a documented urinary tract
infection due to Escherichia coli. Which coding sequence is correct?
A. A41.01, N39.0
B. A41.9, B96.20, N39.0
C. A41.01, B96.20, N39.0
D. A49.01, N39.0
Correct Answer: A
Rationale: Per ICD-10-CM guidelines, when a patient has sepsis due to a specific
organism, the code for the specific organism (A41.01, Sepsis due to Methicillin
susceptible Staphylococcus aureus) is assigned as the principal diagnosis if it meets
principal diagnosis criteria. The UTI due to E. coli is coded as N39.0 (Urinary tract
infection, site not specified) with B96.20 (Unspecified Escherichia coli [E. coli] as the
cause of diseases classified elsewhere) as an additional code to identify the organism.
However, when sepsis is due to a specific organism, the causal organism code (A41.01)
is used rather than B96.20 for the MSSA. The E. coli causing the UTI would be captured
with B96.20 only if the UTI is not specifically linked to the sepsis pathway. Option A
correctly sequences the sepsis due to MSSA and the UTI.
Question 4
Which of the following statements regarding Present on Admission (POA) indicator
assignment is correct?
A. POA indicators are only required on the principal diagnosis
B. POA "Y" means the condition was present at the time of inpatient admission
