AHIMA CDIP EXAM NEWEST 2025
ACTUAL EXAM QUESTIONS AND
DETAILED CORRECT ANSWERS
(VERIFIED ANSWERS) WITH
RATIONALES | CERTIFIED
DOCUMENTATION INTEGRITY
PRACTITIONER
When trying to determine if documentation is present to
substantiate status asthmaticus, the coder should review
the record for what terms and phrases?
A) Intractable pneumonia
B) Refractory asthma and severe, intractable wheezing
C) Airway obstruction relieved by bronchodilators
D) Limited but pronounced wheezing Correct Answer B)
Refractory asthma and severe, intractable wheezing
Mechanical ventilation codes require consideration of:
A) The time when a tracheal tube is inserted
B) The replacement of an endotracheal tube
C) The start time of endotracheal tube insertion followed
by mechanical ventilation
D) Mechanical ventilation during surgery Correct Answer
C) The start time of endotracheal tube insertion followed
by mechanical ventilation
,Abbreviations can be a source of patient safety issues due
to misinterpretation and miscommunication. Abbreviations
in the health record:
A) Are not permitted by Joint Commission standards
B) Should have only one meaning
C) Enhance patient safety
D) Are critical to an electronic health record system
Correct Answer B) Should have only one meaning
When the documentation in the medical record is
insufficient to assign a more specific code, a ___ code is
assigned.
A) MCC
B) CC
C) NOS
D) Unspecified Correct Answer D) Unspecified
A CP patient was admitted with acute bronchitis, possible
pneumonia. In reviewing the diagnoses below what
additionally will impact the patient's ICD-10 code
assignment?
A) Spasticity
B) Quadriplegia
C) Both A and B
D) None of the above Correct Answer C) Both A and B
If a patient undergoes a biopsy immediately before the
definitive surgery for a frozen section, how should this be
coded with ICD-10_PCS codes?
A) The approach to the definitive surgery
B) Suture method
,C) Exploratory surgery
D) Open biopsy and definitive surgery Correct Answer D)
Open biopsy and definitive surgery
A patient had a liver transplant 2 years ago. She has been
experiencing problems with her kidneys with a GFR of 20
and Stage IV CKD. She is noted to have some jaundice.
Based on this:
A) Query should be performed for complication of liver
transplant
B) Query should be performed for complication of liver
transplant
C) Query should not be performed as there are no liver
complications
D) No additional documentation needed for reporting
Correct Answer A) Query should be performed for
complication of liver transplant
When a patient is admitted for treatment of a secondary
malignancy with an active primary site the principle
diagnosis should be:
A) The primary malignancy
B) The secondary malignancy
C) Either condition
D) Query should be performed Correct Answer B) The
secondary malignancy
The Glasgow Coma Scale includes evaluation of:
A) Eye opening response, verbal response, and motor
response
B) Visual response, verbal response, and motor response
, C) Eye opening response, verbal response, and
neurological response
D) None of the above Correct Answer A) Eye opening
response, verbal response, and motor response
Severe sepsis with acute organ dysfunction requires a
code for severe sepsis and:
A) Specific organ dysfunction
B) Underlying infection
C) Sepsis only
D) Multiple organ dysfunction Correct Answer B)
Underlying infection
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) Correct Answer D)
Patient Safety Indicators (PSI)
Terms synonymous with query are clarification, clinical
clarification, documentation alert, and ______?
A) Inquiry
B) Documentation clarification
C) None, query is the only term
D) Physician query Correct Answer B) Documentation
clarification
ACTUAL EXAM QUESTIONS AND
DETAILED CORRECT ANSWERS
(VERIFIED ANSWERS) WITH
RATIONALES | CERTIFIED
DOCUMENTATION INTEGRITY
PRACTITIONER
When trying to determine if documentation is present to
substantiate status asthmaticus, the coder should review
the record for what terms and phrases?
A) Intractable pneumonia
B) Refractory asthma and severe, intractable wheezing
C) Airway obstruction relieved by bronchodilators
D) Limited but pronounced wheezing Correct Answer B)
Refractory asthma and severe, intractable wheezing
Mechanical ventilation codes require consideration of:
A) The time when a tracheal tube is inserted
B) The replacement of an endotracheal tube
C) The start time of endotracheal tube insertion followed
by mechanical ventilation
D) Mechanical ventilation during surgery Correct Answer
C) The start time of endotracheal tube insertion followed
by mechanical ventilation
,Abbreviations can be a source of patient safety issues due
to misinterpretation and miscommunication. Abbreviations
in the health record:
A) Are not permitted by Joint Commission standards
B) Should have only one meaning
C) Enhance patient safety
D) Are critical to an electronic health record system
Correct Answer B) Should have only one meaning
When the documentation in the medical record is
insufficient to assign a more specific code, a ___ code is
assigned.
A) MCC
B) CC
C) NOS
D) Unspecified Correct Answer D) Unspecified
A CP patient was admitted with acute bronchitis, possible
pneumonia. In reviewing the diagnoses below what
additionally will impact the patient's ICD-10 code
assignment?
A) Spasticity
B) Quadriplegia
C) Both A and B
D) None of the above Correct Answer C) Both A and B
If a patient undergoes a biopsy immediately before the
definitive surgery for a frozen section, how should this be
coded with ICD-10_PCS codes?
A) The approach to the definitive surgery
B) Suture method
,C) Exploratory surgery
D) Open biopsy and definitive surgery Correct Answer D)
Open biopsy and definitive surgery
A patient had a liver transplant 2 years ago. She has been
experiencing problems with her kidneys with a GFR of 20
and Stage IV CKD. She is noted to have some jaundice.
Based on this:
A) Query should be performed for complication of liver
transplant
B) Query should be performed for complication of liver
transplant
C) Query should not be performed as there are no liver
complications
D) No additional documentation needed for reporting
Correct Answer A) Query should be performed for
complication of liver transplant
When a patient is admitted for treatment of a secondary
malignancy with an active primary site the principle
diagnosis should be:
A) The primary malignancy
B) The secondary malignancy
C) Either condition
D) Query should be performed Correct Answer B) The
secondary malignancy
The Glasgow Coma Scale includes evaluation of:
A) Eye opening response, verbal response, and motor
response
B) Visual response, verbal response, and motor response
, C) Eye opening response, verbal response, and
neurological response
D) None of the above Correct Answer A) Eye opening
response, verbal response, and motor response
Severe sepsis with acute organ dysfunction requires a
code for severe sepsis and:
A) Specific organ dysfunction
B) Underlying infection
C) Sepsis only
D) Multiple organ dysfunction Correct Answer B)
Underlying infection
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) Correct Answer D)
Patient Safety Indicators (PSI)
Terms synonymous with query are clarification, clinical
clarification, documentation alert, and ______?
A) Inquiry
B) Documentation clarification
C) None, query is the only term
D) Physician query Correct Answer B) Documentation
clarification
