DOCUMENTATION INTEGRITY c
PRACTITIONER (CDI) Exam
c c c
CDIP Questions V8.02
c c
Documentation Integrity c
Practitioner (CDI)
c c
Topics - Certified Documentation
c c c
Integrity Practitioner
c c
messages.downloaded_by
,1.A cquery cshould cbe cgenerated cwhen cdocumentation ccontains ca
A. postoperative chospital-acquired ccondition
B. principal cdiagnosis cwithout can cMCC
C. diagnosis cwithout cclinical cvalidation
D. problem clist cwith csymptoms crelated cto cthe cchief
ccomplaint cAnswer: cC
Explanation:
A cquery cshould cbe cgenerated cwhen cdocumentation ccontains ca cdiagnosis cwithout
cclinical cvalidation, cmeaning cthat cthere cis cno cevidence cin cthe chealth crecord cto
csupport cthe cdiagnosis cor cthat cthe cdiagnosis cis cinconsistent cwith cother cclinical
cindicators. cA cdiagnosis cwithout cclinical cvalidation cmay caffect cthe caccuracy cand
ccompleteness cof ccoding, cquality cmeasures, creimbursement, cand cpatient ccare.
References: cAHIMA/ACDIS. c“Guidelines cfor cAchieving ca cCompliant cQuery cPractice
c(2019 cUpdate).” cJournal cof cAHIMA c90, cno. c2 c(February c2019): c20-29.
2. The cclinical cdocumentation cintegrity c(CDI) cmanager chas cnoted ca cquery cresponse
crate cof c60%. cThe cCDI cpractitioner creports cthat cphysicians coften crespond cverbally
cto cthe cquery.
What ccan cbe cdone cto cimprove cthis crate?
A. Have cCDI cmanager cteaming cwith ccoding csupervisor cto cmonitor cphysician
cresponses
B. Require cphysicians cto cdocument cresponses cin ccharts
C. Permit cCDI cpractitioners cto cdocument cphysician cresponses cin cthe ccharts
D. Allow cphysician cto crespond cvia ce-
mail cAnswer: cB
Explanation:
According cto cthe cAHIMA/ACDIS cQuery cPractice cBrief, cone cof cthe cbest cpractices
cfor ca ccompliant cquery cprocess cis cto crequire cphysicians cto cdocument ctheir
cresponses cto cqueries cin cthe chealth crecord1. cThis censures cthat cthe cdocumentation
cis cconsistent, caccurate, cand ccomplete, cand cthat cthe cquery cand cresponse care cpart
cof cthe cpermanent crecord. cVerbal cresponses care cnot cacceptable, cas cthey cdo cnot
cprovide ca cclear caudit ctrail cand cmay clead cto cerrors cor cdiscrepancies cin ccoding cand
cbilling1. cTherefore, cthe cCDI cmanager cshould ceducate cthe cphysicians con cthe
cimportance cof cdocumenting ctheir cresponses cin cthe ccharts cand cmonitor ctheir
ccompliance. cThe cother coptions care
not crecommended, cas cthey cmay ccompromise cthe cintegrity cof cthe cdocumentation cor
cviolate cthe cquery cguidelines1.
References: cGuidelines cfor cAchieving ca cCompliant cQuery cPractice c(2019
cUpdate) c- cAHIMA
3. The ccorrect ccoding cfor cheart cfailure cwith cpreserved cejection cfraction cis
A. 150.32 cChronic cdiastolic c(congestive) cheart cfailure
B. I50.20 cUnspecified csystolic c(congestive) cheart cfailure
messages.downloaded_by
,C. I50.9 cHeart cfailure, cunspecified
D. I50.30 cUnspecified cdiastolic c(congestive) cheart
cfailure cAnswer: cD
Explanation:
According cto cthe cICD-10-CM cOfficial cGuidelines cfor cCoding cand cReporting cFY
c2023, cheart cfailure cwith cpreserved cejection cfraction c(HFpEF) cis calso cknown cas
cdiastolic cheart cfailure cor cheart cfailure cwith cnormal cejection cfraction1. cThe ccode
ccategory cfor cdiastolic cheart cfailure cis cI50.3-, cwhich cincludes cunspecified cdiastolic
c(congestive) cheart cfailure c(I50.30), cacute cdiastolic c(congestive) cheart cfailure
c(I50.31), cchronic cdiastolic c(congestive) cheart cfailure c(I50.32), cand cacute con cchronic
cdiastolic c(congestive) cheart cfailure c(I50.33)1. cIf cthe cdocumentation cdoes cnot cspecify
cthe cacuity cof cthe cdiastolic cheart cfailure, cthe cdefault ccode cis cI50.301. cTherefore, cthe
ccorrect ccoding cfor cheart cfailure cwith cpreserved cejection cfraction cis cI50.30.
References: cICD-10-CM cOfficial cGuidelines cfor cCoding cand cReporting cFY c20231
4. When ca cchange cin cdepartmental cworkflow cis cnecessary, cthe cfirst cstep cis cto
A. define cthe cgaps cand csolutions
B. set crealistic ctimelines
C. re-engineer cthe cprocess
D. assess cthe ccurrent
cworkflow cAnswer: cD
Explanation:
The cfirst cstep cin cchanging ca cdepartmental cworkflow cis cto cassess cthe ccurrent
cworkflow cand cidentify cthe cproblems cor cinefficiencies cthat cneed cto cbe caddressed.
cThis cwill chelp cto cdefine cthe cgaps cand csolutions, cset crealistic ctimelines, cand cre-
engineer cthe cprocess.
References: cAHIMA. c“CDIP cExam cPreparation.” cAHIMA cPress, cChicago, cIL,
c2017: c125-126.
5. When cqueries care cpart cof cthe chealth crecord, cwhich cof cthe cfollowing cphysician
cprivilege ccould cbe csuspended cif cthe cprovider creceives ctoo cmany cdeficiencies
cdue cto cincomplete crecords cfor cfailure cto crespond cto cqueries?
A. Admitting
B. Consulting
C. Surgical
D. Credentialing
cAnswer: cA
cExplanation:
When cqueries care cpart cof cthe chealth crecord, cwhich cis crecommended cby cAHIMA cand
cACDIS, cphysicians care cresponsible cfor cresponding cto cqueries cin ca ctimely cmanner
cand censuring cthat ctheir cdocumentation cis ccomplete cand caccurate. cIf ca cprovider
creceives ctoo cmany cdeficiencies cdue cto cincomplete crecords cfor cfailure cto crespond cto
cqueries, ctheir
messages.downloaded_by
, admitting cprivilege ccould cbe csuspended cby cthe cmedical cstaff ccommittee cas ca
cdisciplinary caction.
References: cAHIMA/ACDIS. c“Guidelines cfor cAchieving ca cCompliant cQuery cPractice
c(2019 cUpdate).” cJournal cof cAHIMA c90, cno. c2 c(February c2019): c20-29.
6. A c50-year-old cmale cpatient cwas cadmitted cwith ccomplaint cof c3-day
chistory cof cshortness cof cbreath.
Vital csigns:
BP c165/90, cP c90, cT c99.9.F, cO2 csat c95% con croom cair. cPatient chas chistory cof
casthma, cchronic cobstructive cpulmonary cdisease c(COPD), cand chypertension
c(HTN). cHis cmedicines care cAlbuterol cand cNorvasc. cCXR cshowed cchronic clung
cdisease cand cleft clower clobe cinfiltrate. cLabs: cWBC c9.5 cwith c65% csegs. cPhysician
cdocumented cthat cpatient chas casthma cflair cand cadmitted cwith cdecompensated
cCOPD, cordered cIV csteroids, cO2 cat c2L/min cvia cnasal ccannula, cAlbuterol cinhalers
c4x cper cday, cand cClindamycin. cPatient cimproved cand cwas cdischarged c3 cdays
clater.
Which caction cwould chave cthe chighest cimpact con cthe cpatient's cseverity cof cillness
c(SOI) cand crisk cof cmortality c(ROM)?
A. Query cthe cphysician cto cclarify cif cCXR cresult cmeans cpatient chas cpneumonia.
B. Query cthe cphysician cto cclarify cfor ctype cof cCOPD csuch cas csevere casthma.
C. Query cthe cphysician cto cclarify cfor cclinical csignificance cof cthe cCXR cresults.
D. Query cthe cphysician cto cclarify cif cpatient chas cacute cCOPD
cexacerbation. cAnswer: cA
7. A cmodifier cmay cbe cused cin cCPT cand/or cHCPCS ccodes cto cindicate
A. a cservice cor cprocedure cwas cincreased cor creduced
B. a cservice cor cprocedure cwas cperformed cin cits centirety
C. a cservice cor cprocedure cresulted cin cexpected coutcomes
D. a cservice cor cprocedure cwas cperformed cby cone
cprovider cAnswer: cA
Explanation:
According cto cthe cAHIMA cCDIP cExam cPreparation cGuide, ca cmodifier cis ca ctwo-digit
cnumeric cor calphanumeric ccode cthat cmay cbe cused cin cCPT cand/or cHCPCS ccodes
cto cindicate cthat ca cservice cor cprocedure chas cbeen caltered cby csome cspecific
ccircumstance, cbut cnot cchanged cin cits cdefinition cor ccode1. cOne cof cthe creasons cto
cuse ca cmodifier cis cto cindicate cthat ca cservice cor cprocedure cwas cincreased cor
creduced cin ccomparison cto cthe cusual cservice cor cprocedure2. cFor cexample,
cmodifier c22 ccan cbe cused cto creport cincreased cprocedural cservices cthat crequire
csubstantially cgreater ctime, ceffort, cor ccomplexity cthan cthe ctypical cservice3. cThe
cother coptions care cnot ccorrect cbecause cthey cdo cnot creflect cthe cpurpose cof cusing
cmodifiers. cA cservice cor cprocedure cperformed cin cits centirety cdoes cnot cneed ca
cmodifier, cas cit cis cassumed cto cbe cthe cstandard cservice cor cprocedure. cA cservice cor
cprocedure cresulting cin cexpected coutcomes cdoes cnot caffect cthe
messages.downloaded_by
PRACTITIONER (CDI) Exam
c c c
CDIP Questions V8.02
c c
Documentation Integrity c
Practitioner (CDI)
c c
Topics - Certified Documentation
c c c
Integrity Practitioner
c c
messages.downloaded_by
,1.A cquery cshould cbe cgenerated cwhen cdocumentation ccontains ca
A. postoperative chospital-acquired ccondition
B. principal cdiagnosis cwithout can cMCC
C. diagnosis cwithout cclinical cvalidation
D. problem clist cwith csymptoms crelated cto cthe cchief
ccomplaint cAnswer: cC
Explanation:
A cquery cshould cbe cgenerated cwhen cdocumentation ccontains ca cdiagnosis cwithout
cclinical cvalidation, cmeaning cthat cthere cis cno cevidence cin cthe chealth crecord cto
csupport cthe cdiagnosis cor cthat cthe cdiagnosis cis cinconsistent cwith cother cclinical
cindicators. cA cdiagnosis cwithout cclinical cvalidation cmay caffect cthe caccuracy cand
ccompleteness cof ccoding, cquality cmeasures, creimbursement, cand cpatient ccare.
References: cAHIMA/ACDIS. c“Guidelines cfor cAchieving ca cCompliant cQuery cPractice
c(2019 cUpdate).” cJournal cof cAHIMA c90, cno. c2 c(February c2019): c20-29.
2. The cclinical cdocumentation cintegrity c(CDI) cmanager chas cnoted ca cquery cresponse
crate cof c60%. cThe cCDI cpractitioner creports cthat cphysicians coften crespond cverbally
cto cthe cquery.
What ccan cbe cdone cto cimprove cthis crate?
A. Have cCDI cmanager cteaming cwith ccoding csupervisor cto cmonitor cphysician
cresponses
B. Require cphysicians cto cdocument cresponses cin ccharts
C. Permit cCDI cpractitioners cto cdocument cphysician cresponses cin cthe ccharts
D. Allow cphysician cto crespond cvia ce-
mail cAnswer: cB
Explanation:
According cto cthe cAHIMA/ACDIS cQuery cPractice cBrief, cone cof cthe cbest cpractices
cfor ca ccompliant cquery cprocess cis cto crequire cphysicians cto cdocument ctheir
cresponses cto cqueries cin cthe chealth crecord1. cThis censures cthat cthe cdocumentation
cis cconsistent, caccurate, cand ccomplete, cand cthat cthe cquery cand cresponse care cpart
cof cthe cpermanent crecord. cVerbal cresponses care cnot cacceptable, cas cthey cdo cnot
cprovide ca cclear caudit ctrail cand cmay clead cto cerrors cor cdiscrepancies cin ccoding cand
cbilling1. cTherefore, cthe cCDI cmanager cshould ceducate cthe cphysicians con cthe
cimportance cof cdocumenting ctheir cresponses cin cthe ccharts cand cmonitor ctheir
ccompliance. cThe cother coptions care
not crecommended, cas cthey cmay ccompromise cthe cintegrity cof cthe cdocumentation cor
cviolate cthe cquery cguidelines1.
References: cGuidelines cfor cAchieving ca cCompliant cQuery cPractice c(2019
cUpdate) c- cAHIMA
3. The ccorrect ccoding cfor cheart cfailure cwith cpreserved cejection cfraction cis
A. 150.32 cChronic cdiastolic c(congestive) cheart cfailure
B. I50.20 cUnspecified csystolic c(congestive) cheart cfailure
messages.downloaded_by
,C. I50.9 cHeart cfailure, cunspecified
D. I50.30 cUnspecified cdiastolic c(congestive) cheart
cfailure cAnswer: cD
Explanation:
According cto cthe cICD-10-CM cOfficial cGuidelines cfor cCoding cand cReporting cFY
c2023, cheart cfailure cwith cpreserved cejection cfraction c(HFpEF) cis calso cknown cas
cdiastolic cheart cfailure cor cheart cfailure cwith cnormal cejection cfraction1. cThe ccode
ccategory cfor cdiastolic cheart cfailure cis cI50.3-, cwhich cincludes cunspecified cdiastolic
c(congestive) cheart cfailure c(I50.30), cacute cdiastolic c(congestive) cheart cfailure
c(I50.31), cchronic cdiastolic c(congestive) cheart cfailure c(I50.32), cand cacute con cchronic
cdiastolic c(congestive) cheart cfailure c(I50.33)1. cIf cthe cdocumentation cdoes cnot cspecify
cthe cacuity cof cthe cdiastolic cheart cfailure, cthe cdefault ccode cis cI50.301. cTherefore, cthe
ccorrect ccoding cfor cheart cfailure cwith cpreserved cejection cfraction cis cI50.30.
References: cICD-10-CM cOfficial cGuidelines cfor cCoding cand cReporting cFY c20231
4. When ca cchange cin cdepartmental cworkflow cis cnecessary, cthe cfirst cstep cis cto
A. define cthe cgaps cand csolutions
B. set crealistic ctimelines
C. re-engineer cthe cprocess
D. assess cthe ccurrent
cworkflow cAnswer: cD
Explanation:
The cfirst cstep cin cchanging ca cdepartmental cworkflow cis cto cassess cthe ccurrent
cworkflow cand cidentify cthe cproblems cor cinefficiencies cthat cneed cto cbe caddressed.
cThis cwill chelp cto cdefine cthe cgaps cand csolutions, cset crealistic ctimelines, cand cre-
engineer cthe cprocess.
References: cAHIMA. c“CDIP cExam cPreparation.” cAHIMA cPress, cChicago, cIL,
c2017: c125-126.
5. When cqueries care cpart cof cthe chealth crecord, cwhich cof cthe cfollowing cphysician
cprivilege ccould cbe csuspended cif cthe cprovider creceives ctoo cmany cdeficiencies
cdue cto cincomplete crecords cfor cfailure cto crespond cto cqueries?
A. Admitting
B. Consulting
C. Surgical
D. Credentialing
cAnswer: cA
cExplanation:
When cqueries care cpart cof cthe chealth crecord, cwhich cis crecommended cby cAHIMA cand
cACDIS, cphysicians care cresponsible cfor cresponding cto cqueries cin ca ctimely cmanner
cand censuring cthat ctheir cdocumentation cis ccomplete cand caccurate. cIf ca cprovider
creceives ctoo cmany cdeficiencies cdue cto cincomplete crecords cfor cfailure cto crespond cto
cqueries, ctheir
messages.downloaded_by
, admitting cprivilege ccould cbe csuspended cby cthe cmedical cstaff ccommittee cas ca
cdisciplinary caction.
References: cAHIMA/ACDIS. c“Guidelines cfor cAchieving ca cCompliant cQuery cPractice
c(2019 cUpdate).” cJournal cof cAHIMA c90, cno. c2 c(February c2019): c20-29.
6. A c50-year-old cmale cpatient cwas cadmitted cwith ccomplaint cof c3-day
chistory cof cshortness cof cbreath.
Vital csigns:
BP c165/90, cP c90, cT c99.9.F, cO2 csat c95% con croom cair. cPatient chas chistory cof
casthma, cchronic cobstructive cpulmonary cdisease c(COPD), cand chypertension
c(HTN). cHis cmedicines care cAlbuterol cand cNorvasc. cCXR cshowed cchronic clung
cdisease cand cleft clower clobe cinfiltrate. cLabs: cWBC c9.5 cwith c65% csegs. cPhysician
cdocumented cthat cpatient chas casthma cflair cand cadmitted cwith cdecompensated
cCOPD, cordered cIV csteroids, cO2 cat c2L/min cvia cnasal ccannula, cAlbuterol cinhalers
c4x cper cday, cand cClindamycin. cPatient cimproved cand cwas cdischarged c3 cdays
clater.
Which caction cwould chave cthe chighest cimpact con cthe cpatient's cseverity cof cillness
c(SOI) cand crisk cof cmortality c(ROM)?
A. Query cthe cphysician cto cclarify cif cCXR cresult cmeans cpatient chas cpneumonia.
B. Query cthe cphysician cto cclarify cfor ctype cof cCOPD csuch cas csevere casthma.
C. Query cthe cphysician cto cclarify cfor cclinical csignificance cof cthe cCXR cresults.
D. Query cthe cphysician cto cclarify cif cpatient chas cacute cCOPD
cexacerbation. cAnswer: cA
7. A cmodifier cmay cbe cused cin cCPT cand/or cHCPCS ccodes cto cindicate
A. a cservice cor cprocedure cwas cincreased cor creduced
B. a cservice cor cprocedure cwas cperformed cin cits centirety
C. a cservice cor cprocedure cresulted cin cexpected coutcomes
D. a cservice cor cprocedure cwas cperformed cby cone
cprovider cAnswer: cA
Explanation:
According cto cthe cAHIMA cCDIP cExam cPreparation cGuide, ca cmodifier cis ca ctwo-digit
cnumeric cor calphanumeric ccode cthat cmay cbe cused cin cCPT cand/or cHCPCS ccodes
cto cindicate cthat ca cservice cor cprocedure chas cbeen caltered cby csome cspecific
ccircumstance, cbut cnot cchanged cin cits cdefinition cor ccode1. cOne cof cthe creasons cto
cuse ca cmodifier cis cto cindicate cthat ca cservice cor cprocedure cwas cincreased cor
creduced cin ccomparison cto cthe cusual cservice cor cprocedure2. cFor cexample,
cmodifier c22 ccan cbe cused cto creport cincreased cprocedural cservices cthat crequire
csubstantially cgreater ctime, ceffort, cor ccomplexity cthan cthe ctypical cservice3. cThe
cother coptions care cnot ccorrect cbecause cthey cdo cnot creflect cthe cpurpose cof cusing
cmodifiers. cA cservice cor cprocedure cperformed cin cits centirety cdoes cnot cneed ca
cmodifier, cas cit cis cassumed cto cbe cthe cstandard cservice cor cprocedure. cA cservice cor
cprocedure cresulting cin cexpected coutcomes cdoes cnot caffect cthe
messages.downloaded_by
