CERTIFIED DOCUMENTATION INTEGRITY PRACTITIONER {CDIP} EXAM
CONTAINS 130 QUESTIONS AND CORRECT, DETAILED & VERIFIED
ANSWERS WITH DETAILED EXPLANATIONS| LATEST CDIP ACTUAL
EXAM (GUARANTEED PASS/AHIMA)
A CDI program should be governed by policies and procedures. These policies and procedures should be
developed with the assistance of other departments affected by clinical documentation, including
compliance, case management, and what other department?
a.Information systems
b.Process improvement
c.Health Information Management (HIM)
d.Finance - correct answer -c
HIM These policies and procedures should be developed with the assistance of other departments
affected by clinical documentation, including compliance, case management, and HIM (AHIMA 2013b).
Providers should maintain queries:
a.Indefinitely
b.Based on their facility policy
c.Never
d.Until the patient expires - correct answer –b
Based on your facility policy. Retention of the query varies by healthcare organization. First, an
organization must determine if the query will be part of the health record. If the query is not part of the
health record, then the organization must decide if the query is kept as part of the business record or
only the outcome of the query is maintained in a database (AHIMA 2013b).
The new CDI manager has decided the query will become a part of the health record stating this is
required.
a.The query has to be a part of the health record
b.An organization must determine if the query will be part of the health record
c.The query should be disposed of after completion
d.All queries should be verbal - correct answer –b
, It is the decision of an organization of how to maintain queries and whether to include them as part of
the health record. . Retention of the query varies by healthcare organization. First, an organization must
determine if the query will be part of the health record. If the query is not part of the health record,
then the organization must decide if the query is kept as part of the business record or only the outcome
of the query is maintained in a database (AHIMA 2013b).
Erin is the HIM director at Anywhere Hospital. She is teaching a class to clinicians about proper
documentation in the health record. Which of the following would she not instruct them to do?
a.Obliterate errors
b.Leave existing entries intact
c.Label late entries as being late
d.Ensure the legal signature of an individual making a correction accompanies the correction - correct
answer -a
Any corrections to the record must be entered properly. In paper records, the provider should draw a
single line through the error, add a note explaining the error, initial and date the error with the date it
was discovered, and enter the correct information in chronological order. For electronic entries, a
procedure should be followed that explains how to correct errors and enter addenda to the health
record (Shaw and Carter 2014; LaTour et al. 2013, 264).
The Clinical Documentation Program at ABCD Medical Center has made significant strides to improve
their physician engagement at their facility and had reduced their physician response to 98 percent over
a one year period. Their CMO has recommended the team share their success by:
a.Not put too much emphasis on the initiative
b.Publish this in a research journal for physician education and facility awareness
c.Make adjustments to their CDI process as 80 percent compliance is the facility goal
d.None of the above - correct answer –b
Performing research around the CDI initiatives and writing publications can be beneficial for the CDI
program and the facility. This co-development can also foster physician understanding in the process
and individual documentation accountability. To communicate effectively, managers must pay just as
much attention to how their message is received and interpreted as they do to its content. In order to
enhance the accuracy and acceptance of communication, the communicator needs to monitor others'
nonverbal behaviors for cues that they are following or confused. Passive listening and distracted parties
would not enhance effective communication (Shaw and Carter 2014; Hess 2015, 231).
,The financial statement that presents a record of operations by showing revenue and expenses over a
period of time is called the:
a.Income statement
b.Balance sheet
c.Statement of cash flows
d.Statement of retained earnings - correct answer –a
An income statement summarizes the organization's revenue and expense transactions during the fiscal
year. The income statement can be prepared at any point in time and reflects results up to that point
(Shaw and Carter 2014; LaTour et al. 2013, 777).
If the physician does not document the diagnosis, the coding professional cannot assume the patient
has a diagnosis based solely on
a.An abnormal lab finding
b.Abnormal pathology reports
c.Both A and B
d.None of the above - correct answer -c
The coder cannot assume diagnoses on abnormal findings such as lab reports. Abnormal findings
(laboratory, X-ray, pathologic, and other diagnostic results) are not coded and reported unless the
physician indicates their clinical significance. If the findings are outside the normal range and the
physician has ordered other tests to evaluate the condition or prescribed treatment, it is appropriate to
ask the physician whether the diagnosis should be added (AHA 1990, 15).
These documents would be used for are used by clinicians and providers to identify abnormal
temperature, blood pressure, pulse, respiration, oxygen levels, and other indicators.
a.Nurses' graphic records
b.Vital sign flowsheets
c.Both A and B
d.None of the above - correct answer -c
Clinicians and providers utilize various documents to identify abnormal temperature, blood pressure,
pulse, respiration, oxygen levels, and other indicators. These documents are often called nurses' graphic
records or vital sign flowsheets (Hess 2015, 43).
, The American Hospital Association (AHA), the American Health Information Management Association
(AHIMA), Center for Medicare and Medicaid Services (CMS), and National Center for Healthcare
Statistics (NCHS) are all
a.Cooperating parties
b.Governing bodies
c.Coding associations
d.Work independently to develop coding guidelines - correct answer -a
The American Hospital Association (AHA), the American Health Information Management Association
(AHIMA), Center for Medicare and Medicaid Services (CMS), and National Center for Health Statistics
(NCHS) are all cooperating parties that developed and approved ICD-10-CM/PCS (ICD-10-CM Official
Guidelines for Coding and Reporting 2016a, 1).
A patient was admitted with HIV and pneumocystic carini. The patient should have a principal diagnosis
in ICD-10 of:
a.AIDS
b.Asymptomatic HIV
c.Pneumonia
d.Not enough information - correct answer -a
If a patient is admitted for an HIV-related condition, the principal diagnosis should be B20, Human
immunodeficiency virus [HIV] disease followed by additional diagnosis codes for all reported HIV-related
conditions (ICD-10-CM Official Guidelines for Coding and Reporting 2016a, 17).
APR-DRGs have levels (subclasses) of severity entitled:
a.Excessive, Major, Moderate, Minor
b.Extreme, Major, Moderate, Minor
c.Extreme, Major, Moderate, Minimal
d.Excessive, Major - correct answer -b
The APR-DRG system is distributed into levels (subclasses) similar to MS-DRGs. These levels are entitled
Extreme, Major, Moderate, Minor (Hess 2015, 48)
During an outpatient procedure for removal of a bladder cyst, the urologist accidentally tore the
urethral sphincter requiring an observation stay. This should be assigned as the principal diagnosis:
CONTAINS 130 QUESTIONS AND CORRECT, DETAILED & VERIFIED
ANSWERS WITH DETAILED EXPLANATIONS| LATEST CDIP ACTUAL
EXAM (GUARANTEED PASS/AHIMA)
A CDI program should be governed by policies and procedures. These policies and procedures should be
developed with the assistance of other departments affected by clinical documentation, including
compliance, case management, and what other department?
a.Information systems
b.Process improvement
c.Health Information Management (HIM)
d.Finance - correct answer -c
HIM These policies and procedures should be developed with the assistance of other departments
affected by clinical documentation, including compliance, case management, and HIM (AHIMA 2013b).
Providers should maintain queries:
a.Indefinitely
b.Based on their facility policy
c.Never
d.Until the patient expires - correct answer –b
Based on your facility policy. Retention of the query varies by healthcare organization. First, an
organization must determine if the query will be part of the health record. If the query is not part of the
health record, then the organization must decide if the query is kept as part of the business record or
only the outcome of the query is maintained in a database (AHIMA 2013b).
The new CDI manager has decided the query will become a part of the health record stating this is
required.
a.The query has to be a part of the health record
b.An organization must determine if the query will be part of the health record
c.The query should be disposed of after completion
d.All queries should be verbal - correct answer –b
, It is the decision of an organization of how to maintain queries and whether to include them as part of
the health record. . Retention of the query varies by healthcare organization. First, an organization must
determine if the query will be part of the health record. If the query is not part of the health record,
then the organization must decide if the query is kept as part of the business record or only the outcome
of the query is maintained in a database (AHIMA 2013b).
Erin is the HIM director at Anywhere Hospital. She is teaching a class to clinicians about proper
documentation in the health record. Which of the following would she not instruct them to do?
a.Obliterate errors
b.Leave existing entries intact
c.Label late entries as being late
d.Ensure the legal signature of an individual making a correction accompanies the correction - correct
answer -a
Any corrections to the record must be entered properly. In paper records, the provider should draw a
single line through the error, add a note explaining the error, initial and date the error with the date it
was discovered, and enter the correct information in chronological order. For electronic entries, a
procedure should be followed that explains how to correct errors and enter addenda to the health
record (Shaw and Carter 2014; LaTour et al. 2013, 264).
The Clinical Documentation Program at ABCD Medical Center has made significant strides to improve
their physician engagement at their facility and had reduced their physician response to 98 percent over
a one year period. Their CMO has recommended the team share their success by:
a.Not put too much emphasis on the initiative
b.Publish this in a research journal for physician education and facility awareness
c.Make adjustments to their CDI process as 80 percent compliance is the facility goal
d.None of the above - correct answer –b
Performing research around the CDI initiatives and writing publications can be beneficial for the CDI
program and the facility. This co-development can also foster physician understanding in the process
and individual documentation accountability. To communicate effectively, managers must pay just as
much attention to how their message is received and interpreted as they do to its content. In order to
enhance the accuracy and acceptance of communication, the communicator needs to monitor others'
nonverbal behaviors for cues that they are following or confused. Passive listening and distracted parties
would not enhance effective communication (Shaw and Carter 2014; Hess 2015, 231).
,The financial statement that presents a record of operations by showing revenue and expenses over a
period of time is called the:
a.Income statement
b.Balance sheet
c.Statement of cash flows
d.Statement of retained earnings - correct answer –a
An income statement summarizes the organization's revenue and expense transactions during the fiscal
year. The income statement can be prepared at any point in time and reflects results up to that point
(Shaw and Carter 2014; LaTour et al. 2013, 777).
If the physician does not document the diagnosis, the coding professional cannot assume the patient
has a diagnosis based solely on
a.An abnormal lab finding
b.Abnormal pathology reports
c.Both A and B
d.None of the above - correct answer -c
The coder cannot assume diagnoses on abnormal findings such as lab reports. Abnormal findings
(laboratory, X-ray, pathologic, and other diagnostic results) are not coded and reported unless the
physician indicates their clinical significance. If the findings are outside the normal range and the
physician has ordered other tests to evaluate the condition or prescribed treatment, it is appropriate to
ask the physician whether the diagnosis should be added (AHA 1990, 15).
These documents would be used for are used by clinicians and providers to identify abnormal
temperature, blood pressure, pulse, respiration, oxygen levels, and other indicators.
a.Nurses' graphic records
b.Vital sign flowsheets
c.Both A and B
d.None of the above - correct answer -c
Clinicians and providers utilize various documents to identify abnormal temperature, blood pressure,
pulse, respiration, oxygen levels, and other indicators. These documents are often called nurses' graphic
records or vital sign flowsheets (Hess 2015, 43).
, The American Hospital Association (AHA), the American Health Information Management Association
(AHIMA), Center for Medicare and Medicaid Services (CMS), and National Center for Healthcare
Statistics (NCHS) are all
a.Cooperating parties
b.Governing bodies
c.Coding associations
d.Work independently to develop coding guidelines - correct answer -a
The American Hospital Association (AHA), the American Health Information Management Association
(AHIMA), Center for Medicare and Medicaid Services (CMS), and National Center for Health Statistics
(NCHS) are all cooperating parties that developed and approved ICD-10-CM/PCS (ICD-10-CM Official
Guidelines for Coding and Reporting 2016a, 1).
A patient was admitted with HIV and pneumocystic carini. The patient should have a principal diagnosis
in ICD-10 of:
a.AIDS
b.Asymptomatic HIV
c.Pneumonia
d.Not enough information - correct answer -a
If a patient is admitted for an HIV-related condition, the principal diagnosis should be B20, Human
immunodeficiency virus [HIV] disease followed by additional diagnosis codes for all reported HIV-related
conditions (ICD-10-CM Official Guidelines for Coding and Reporting 2016a, 17).
APR-DRGs have levels (subclasses) of severity entitled:
a.Excessive, Major, Moderate, Minor
b.Extreme, Major, Moderate, Minor
c.Extreme, Major, Moderate, Minimal
d.Excessive, Major - correct answer -b
The APR-DRG system is distributed into levels (subclasses) similar to MS-DRGs. These levels are entitled
Extreme, Major, Moderate, Minor (Hess 2015, 48)
During an outpatient procedure for removal of a bladder cyst, the urologist accidentally tore the
urethral sphincter requiring an observation stay. This should be assigned as the principal diagnosis:
