AHIMA CDIP: CERTIFIED DOCUMENTATION IMPROVEMENT PRACTITIONER |
100% VERIFIED TEST BANK EXAM QUESTIONS AND ANSWERS | LATEST
2026/2027 VERSION (PASS GUARANTEE)
1. Which of the following best describes the primary goal of a Clinical
Documentation Improvement (CDI) program?
A. Increase hospital revenue by maximizing DRG assignments
B. Ensure that clinical documentation accurately reflects the patient's clinical
status and supports appropriate coding ANSWER
C. Reduce physician workload by streamlining documentation requirements
D. Minimize the number of medical record queries sent to physicians
2. A CDIP specialist reviews a record and notes that a patient with a blood pressure
of 170/100 mmHg has no documented diagnosis of hypertension. The most
appropriate action is to:
A. Code hypertension based on clinical indicators alone
B. Submit a compliant query to the physician to clarify whether hypertension
should be documented ANSWER
C. Ignore the finding since the physician did not document the diagnosis
D. Code the elevated blood pressure reading as hypertension
3. Under the MS-DRG system, the principal diagnosis is defined as:
A. The most resource-intensive condition during the hospital stay
B. The condition established after study to be chiefly responsible for the
admission ANSWER
C. The first diagnosis listed on the discharge summary
D. The condition with the highest severity of illness weight
Page 1 of 47
,4. Which regulatory body provides the Uniform Hospital Discharge Data Set
(UHDDS) definitions used in inpatient coding?
A. American Hospital Association (AHA)
B. Centers for Medicare & Medicaid Services (CMS)
C. Department of Health and Human Services (DHHS) ANSWER
D. American Health Information Management Association (AHIMA)
5. A CDI specialist is calculating the Case Mix Index (CMI) for a hospital unit.
CMI is best described as:
A. The total number of Medicare discharges divided by total admissions
B. The average DRG relative weight for a set of patient discharges ANSWER
C. The ratio of surgical to medical cases in a given time period
D. The percentage of cases that have a complication or comorbidity
6. Which of the following is an example of a major complication or comorbidity
(MCC) in the MS-DRG system?
A. Type 2 diabetes mellitus without complications
B. Acute respiratory failure ANSWER
C. Essential hypertension
D. Mild anemia
7. When a CDI specialist sends a query regarding a patient's nutritional status,
which level of malnutrition would have the greatest impact on the DRG
assignment?
A. Mild malnutrition
B. Moderate malnutrition
C. Severe malnutrition ANSWER
D. Nutritional deficiency, unspecified
8. The Hospital-Acquired Condition (HAC) reduction program penalizes hospitals
for conditions that:
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, A. Were present on admission and not treated
B. Could have been prevented and were not present on admission ANSWER
C. Resulted in a longer length of stay regardless of cause
D. Were secondary to the principal diagnosis
9. A CDI professional reviews a patient's record and finds documentation of 'SIRS
due to non-infectious process.' According to ICD-10-CM guidelines, the coder
should:
A. Code sepsis as the principal diagnosis
B. Code the underlying condition first, followed by SIRS ANSWER
C. Query the physician to confirm or rule out sepsis
D. Code only the underlying non-infectious condition
10. Which of the following is a key metric used to evaluate CDI program
effectiveness?
A. Physician satisfaction scores
B. Query response rate and agreement rate ANSWER
C. Number of records reviewed per week
D. Nurse-to-patient ratios on the unit
11. The 'present on admission' (POA) indicator is required for:
A. All outpatient diagnoses
B. Principal and secondary diagnoses on inpatient Medicare claims ANSWER
C. Emergency department visits only
D. All CPT procedure codes
12. Which of the following best describes a 'concurrent' CDI review?
A. Review of a record after the patient has been discharged
B. Review of a record while the patient is still admitted ANSWER
C. Review focused solely on coding accuracy post-discharge
D. Review conducted by an external auditor annually
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, 13. Under APR-DRG methodology, which factor is used to determine the severity
of illness subclass?
A. Length of stay only
B. Patient age and diagnoses affecting complexity of care ANSWER
C. Number of surgical procedures performed
D. The attending physician's specialty
14. A CDI specialist identifies that a patient was admitted with pneumonia but the
sputum culture grew Pseudomonas aeruginosa. The specialist should:
A. Code only the organism Pseudomonas aeruginosa as principal diagnosis
B. Query the physician to confirm whether the pneumonia is due to
Pseudomonas ANSWER
C. Code pneumonia, organism unspecified since sputum cultures are not
definitive
D. Add the organism code without querying since lab results are objective
15. Which ICD-10-CM code category is used to report sepsis?
A. A40–A41 ANSWER
B. B95–B97
C. J18
D. R65
16. The CDI team's role in value-based purchasing programs primarily involves
ensuring:
A. Maximum reimbursement for all encounters regardless of clinical accuracy
B. Accurate capture of quality measures and risk-adjusted outcomes
ANSWER
C. Reduction of all complications to avoid financial penalties
D. Elimination of physician queries to reduce administrative burden
17. When querying for encephalopathy, which type has the greatest coding impact
as an MCC?
A. Metabolic encephalopathy ANSWER
Page 4 of 47
100% VERIFIED TEST BANK EXAM QUESTIONS AND ANSWERS | LATEST
2026/2027 VERSION (PASS GUARANTEE)
1. Which of the following best describes the primary goal of a Clinical
Documentation Improvement (CDI) program?
A. Increase hospital revenue by maximizing DRG assignments
B. Ensure that clinical documentation accurately reflects the patient's clinical
status and supports appropriate coding ANSWER
C. Reduce physician workload by streamlining documentation requirements
D. Minimize the number of medical record queries sent to physicians
2. A CDIP specialist reviews a record and notes that a patient with a blood pressure
of 170/100 mmHg has no documented diagnosis of hypertension. The most
appropriate action is to:
A. Code hypertension based on clinical indicators alone
B. Submit a compliant query to the physician to clarify whether hypertension
should be documented ANSWER
C. Ignore the finding since the physician did not document the diagnosis
D. Code the elevated blood pressure reading as hypertension
3. Under the MS-DRG system, the principal diagnosis is defined as:
A. The most resource-intensive condition during the hospital stay
B. The condition established after study to be chiefly responsible for the
admission ANSWER
C. The first diagnosis listed on the discharge summary
D. The condition with the highest severity of illness weight
Page 1 of 47
,4. Which regulatory body provides the Uniform Hospital Discharge Data Set
(UHDDS) definitions used in inpatient coding?
A. American Hospital Association (AHA)
B. Centers for Medicare & Medicaid Services (CMS)
C. Department of Health and Human Services (DHHS) ANSWER
D. American Health Information Management Association (AHIMA)
5. A CDI specialist is calculating the Case Mix Index (CMI) for a hospital unit.
CMI is best described as:
A. The total number of Medicare discharges divided by total admissions
B. The average DRG relative weight for a set of patient discharges ANSWER
C. The ratio of surgical to medical cases in a given time period
D. The percentage of cases that have a complication or comorbidity
6. Which of the following is an example of a major complication or comorbidity
(MCC) in the MS-DRG system?
A. Type 2 diabetes mellitus without complications
B. Acute respiratory failure ANSWER
C. Essential hypertension
D. Mild anemia
7. When a CDI specialist sends a query regarding a patient's nutritional status,
which level of malnutrition would have the greatest impact on the DRG
assignment?
A. Mild malnutrition
B. Moderate malnutrition
C. Severe malnutrition ANSWER
D. Nutritional deficiency, unspecified
8. The Hospital-Acquired Condition (HAC) reduction program penalizes hospitals
for conditions that:
Page 2 of 47
, A. Were present on admission and not treated
B. Could have been prevented and were not present on admission ANSWER
C. Resulted in a longer length of stay regardless of cause
D. Were secondary to the principal diagnosis
9. A CDI professional reviews a patient's record and finds documentation of 'SIRS
due to non-infectious process.' According to ICD-10-CM guidelines, the coder
should:
A. Code sepsis as the principal diagnosis
B. Code the underlying condition first, followed by SIRS ANSWER
C. Query the physician to confirm or rule out sepsis
D. Code only the underlying non-infectious condition
10. Which of the following is a key metric used to evaluate CDI program
effectiveness?
A. Physician satisfaction scores
B. Query response rate and agreement rate ANSWER
C. Number of records reviewed per week
D. Nurse-to-patient ratios on the unit
11. The 'present on admission' (POA) indicator is required for:
A. All outpatient diagnoses
B. Principal and secondary diagnoses on inpatient Medicare claims ANSWER
C. Emergency department visits only
D. All CPT procedure codes
12. Which of the following best describes a 'concurrent' CDI review?
A. Review of a record after the patient has been discharged
B. Review of a record while the patient is still admitted ANSWER
C. Review focused solely on coding accuracy post-discharge
D. Review conducted by an external auditor annually
Page 3 of 47
, 13. Under APR-DRG methodology, which factor is used to determine the severity
of illness subclass?
A. Length of stay only
B. Patient age and diagnoses affecting complexity of care ANSWER
C. Number of surgical procedures performed
D. The attending physician's specialty
14. A CDI specialist identifies that a patient was admitted with pneumonia but the
sputum culture grew Pseudomonas aeruginosa. The specialist should:
A. Code only the organism Pseudomonas aeruginosa as principal diagnosis
B. Query the physician to confirm whether the pneumonia is due to
Pseudomonas ANSWER
C. Code pneumonia, organism unspecified since sputum cultures are not
definitive
D. Add the organism code without querying since lab results are objective
15. Which ICD-10-CM code category is used to report sepsis?
A. A40–A41 ANSWER
B. B95–B97
C. J18
D. R65
16. The CDI team's role in value-based purchasing programs primarily involves
ensuring:
A. Maximum reimbursement for all encounters regardless of clinical accuracy
B. Accurate capture of quality measures and risk-adjusted outcomes
ANSWER
C. Reduction of all complications to avoid financial penalties
D. Elimination of physician queries to reduce administrative burden
17. When querying for encephalopathy, which type has the greatest coding impact
as an MCC?
A. Metabolic encephalopathy ANSWER
Page 4 of 47
