CERTIFIED DOCUMENTATION INTEGRITY PRACTITIONER) CDIP
EXAM 2025-2026 CONTAINS 200 QUESTIONS AND CORRECT,
DETAILED & VERIFIED ANSWERS WITH RATIONALES| LATEST CDIP
ACTUAL EXAM 2025 (GUARANTEED PASS}
A CDI program should allow concurrent documentation review to:
a.educate clinical care providers
b.allow providers to clarify hospital acquired conditions and present on admission indicators
c.address areas of quality impact
d.all of the above - CORRECT ANSWER-d Queries should address areas of quality impact such as
present on admission indicators and hospital acquired conditions (Hess 2015, 234).
A patient has a stage III pressure ulcer noted in the ED. While the patient is in the hospital for 6 days,
the ulcer progresses to stage IV. The correct POA assignment would be:
a.Y-yes
b.N-no
c.U-unknown
d.None of the above - CORRECT ANSWER-a The pressure ulcer was noted on admission. Assign "Y"
for conditions diagnosed during the admission that were clearly present but not diagnosed until
after admission occurred (ICD-10-CM Official Guidelines for Coding and Reporting 2016b, 109).
The following query was found in a patient's health record. Which of the answers best applies to this
query?
Dr. Bean: This patient received IV Rocephin and Vancomycin; please document severe sepsis in the
progress note to justify the drug utilization.
a.This is a leading query
b.This query brings in information not documented within the chart and is inappropriate
c.This is a yes or no query
d.This is an appropriate query - CORRECT ANSWER-a When formulating a query, it is unacceptable to
lead a provider to document a particular response. The query should not be directing or probing and
the provider should not be led to make an assumption (Lovaasen and Schwerdtfeger 2011, 42; HHS
2014, Section I.B.16., 16)
The following query was found in a patient's health record. Which of the answers best applies to this
query?
,Dr. Bean: This patient was admitted with dizziness, coffee-ground emesis and severe, burning
abdominal pain. The patient has a history of gastric ulcers with repeated admissions for alcoholism
and habitual use of NSAIDS. Laboratory shows hemoglobin of 10 with transfusion of 2 units RBCs.
Patient has anemia. Please document the type of anemia noted within your progress note.
a.This is a leading query
b.This query brings in information not documented within the chart and is inappropriate
c.This is a yes or no query
d.This is an appropriate query - CORRECT ANSWER-d With the documented clinical indicators, it
would be appropriate to query the physician regarding the possibility of a complication resulting
from surgery. (Lovaasen and Schwerdtfeger 2011, 42; HHS 2014, Section I.B. 16., 16).
The following query was found in a patient's health record. Which of the answers best applies to this
query?
Dr. Bean: It was noted within the record that the patient has cellulitis of the foot. Please specify the
laterality of the patient's cellulitis.
a.This is a leading query
b.This query brings in information not documented within the chart and is inappropriate
c.This is a yes or no query
d.This is an appropriate query - CORRECT ANSWER-d If there is evidence of a diagnosis within the
medical record and the coder is uncertain whether it is a valid diagnosis because the documentation
is incomplete, it is the coder's responsibility to query the attending physician to determine if this
diagnosis should be included (Leon-Chisen 2013, 43-44).
The following query was found in a patient's health record. Which of the answers best applies to this
query?
Dr. Bean: It is evident within the record that the patient has a diagnosis of CKD stage V. As the
patient has a long history of diabetes and hypertension, please document this as the cause of the
CKD in this patient on dialysis.
a.This is a leading query
b.This query brings in information not documented within the chart and is inappropriate
c.This is a yes or no query
d.This is an appropriate query - CORRECT ANSWER-a When formulating a query, it is unacceptable to
lead a provider to document a particular response. The query should not be directing or probing and
the provider should not be led to make an assumption (Lovaasen and Schwerdtfeger 2011, 42; HHS
2014, Section I.B.16., 16).
,The following query was found in a patient's health record. Which of the answers best applies to this
query?
Dr. Bean: This patient was treated for both a primary neoplasm and a secondary neoplasm based on
documentation with the record. Was the focus of the treatment the secondary neoplasm?
a.This is a leading query
b.This query brings in information not documented within the chart and is inappropriate
c.This is a yes or no query
d.This is an appropriate query - CORRECT ANSWER-c If there is evidence of a diagnosis within the
medical record and the coder is uncertain whether it is a valid diagnosis because the documentation
is incomplete, it is the coder's responsibility to query the attending physician to determine if this
diagnosis should be included (Leon-Chisen 2013, 43-44).
An inpatient undergoes a procedure and has a postoperative complication during the
hospitalization. The insurance company will not pay for the entire amount requested. Which POA
indicator is likely part of the cause?
a.N
b.Y
c.W
d.U - CORRECT ANSWER-a The postoperative complication that is not present at admission. The
insurance company may not pay for the services provided to take care of the postoperative
complication (Garrett 2009, 11).
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 Status asthmaticus is defined as
continual wheezing in spite of therapy (Leon-Chisen 2013, 230).
Within the postoperative patient, this is the most common type of shock. It occurs when large
amounts of fluids are lost from hemorrhage or severe dehydration.
a.Cardiogenic
b.Renal
c.Hypovolemic
, d.Neurologic - CORRECT ANSWER-c Hypovolemic shock is the most common type of shock seen in
the postoperative patient. It occurs when large amounts of fluids are lost from hemorrhage or
severe dehydration (AHA 2011, 150).
The procedure that was performed for the definitive treatment (rather than the diagnosis) of the
main condition, or a complication of the condition is the:
a.Chief procedure
b.Principal treatment
c.Principal procedure
d.Comorbidity - CORRECT ANSWER-c The principal procedure is the procedure that was performed
for the definitive treatment (rather than the diagnosis) of the main condition or a complication of
the condition (Shaw and Carter 2014; LaTour et al. 2013, 432,940).
A physician query may not be appropriate in which of the following instances?
a.Diagnosis of viral pneumonia noted in the progress notes and sputum cultures showing
Haemophilus influenzae
b.Discharge summary indicates chronic renal failure but the progress notes document acute renal
failure throughout the stay
c.Acute respiratory failure in a patient whose lab report findings appear to not support this diagnosis
d.Diagnosis of chest pain and abnormal cardiac enzymes indicative of an AMI - CORRECT ANSWER-c
A query may not be appropriate because the clinical information or clinical picture does not appear
to support the documentation of a condition or procedure. In situations in which the provider's
documented diagnosis does not appear to be supported by clinical findings, a healthcare entity's
policies can provide guidance on a process for addressing the issue without querying the attending
physician (Shaw and Carter 2014; Schraffenberger and Kuehn 2011, 348).
Who is responsible for the content, quality, and signing of the discharge summary?
a.Attending physician
b.Head nurse
c.Consulting physician
d.Admitting nurse - CORRECT ANSWER-a The physician principally responsible for the patient's
hospital care generally dictates the discharge summary. However, a resident, physician assistant, or
nurse practitioner who is being supervised by the attending physician may complete this task.
Regardless of who documents it, the attending physician is responsible for the content and quality of
the summary and must date and sign it Shaw and Carter 2014; Fahrenholz and Russo 2013, 284).
EXAM 2025-2026 CONTAINS 200 QUESTIONS AND CORRECT,
DETAILED & VERIFIED ANSWERS WITH RATIONALES| LATEST CDIP
ACTUAL EXAM 2025 (GUARANTEED PASS}
A CDI program should allow concurrent documentation review to:
a.educate clinical care providers
b.allow providers to clarify hospital acquired conditions and present on admission indicators
c.address areas of quality impact
d.all of the above - CORRECT ANSWER-d Queries should address areas of quality impact such as
present on admission indicators and hospital acquired conditions (Hess 2015, 234).
A patient has a stage III pressure ulcer noted in the ED. While the patient is in the hospital for 6 days,
the ulcer progresses to stage IV. The correct POA assignment would be:
a.Y-yes
b.N-no
c.U-unknown
d.None of the above - CORRECT ANSWER-a The pressure ulcer was noted on admission. Assign "Y"
for conditions diagnosed during the admission that were clearly present but not diagnosed until
after admission occurred (ICD-10-CM Official Guidelines for Coding and Reporting 2016b, 109).
The following query was found in a patient's health record. Which of the answers best applies to this
query?
Dr. Bean: This patient received IV Rocephin and Vancomycin; please document severe sepsis in the
progress note to justify the drug utilization.
a.This is a leading query
b.This query brings in information not documented within the chart and is inappropriate
c.This is a yes or no query
d.This is an appropriate query - CORRECT ANSWER-a When formulating a query, it is unacceptable to
lead a provider to document a particular response. The query should not be directing or probing and
the provider should not be led to make an assumption (Lovaasen and Schwerdtfeger 2011, 42; HHS
2014, Section I.B.16., 16)
The following query was found in a patient's health record. Which of the answers best applies to this
query?
,Dr. Bean: This patient was admitted with dizziness, coffee-ground emesis and severe, burning
abdominal pain. The patient has a history of gastric ulcers with repeated admissions for alcoholism
and habitual use of NSAIDS. Laboratory shows hemoglobin of 10 with transfusion of 2 units RBCs.
Patient has anemia. Please document the type of anemia noted within your progress note.
a.This is a leading query
b.This query brings in information not documented within the chart and is inappropriate
c.This is a yes or no query
d.This is an appropriate query - CORRECT ANSWER-d With the documented clinical indicators, it
would be appropriate to query the physician regarding the possibility of a complication resulting
from surgery. (Lovaasen and Schwerdtfeger 2011, 42; HHS 2014, Section I.B. 16., 16).
The following query was found in a patient's health record. Which of the answers best applies to this
query?
Dr. Bean: It was noted within the record that the patient has cellulitis of the foot. Please specify the
laterality of the patient's cellulitis.
a.This is a leading query
b.This query brings in information not documented within the chart and is inappropriate
c.This is a yes or no query
d.This is an appropriate query - CORRECT ANSWER-d If there is evidence of a diagnosis within the
medical record and the coder is uncertain whether it is a valid diagnosis because the documentation
is incomplete, it is the coder's responsibility to query the attending physician to determine if this
diagnosis should be included (Leon-Chisen 2013, 43-44).
The following query was found in a patient's health record. Which of the answers best applies to this
query?
Dr. Bean: It is evident within the record that the patient has a diagnosis of CKD stage V. As the
patient has a long history of diabetes and hypertension, please document this as the cause of the
CKD in this patient on dialysis.
a.This is a leading query
b.This query brings in information not documented within the chart and is inappropriate
c.This is a yes or no query
d.This is an appropriate query - CORRECT ANSWER-a When formulating a query, it is unacceptable to
lead a provider to document a particular response. The query should not be directing or probing and
the provider should not be led to make an assumption (Lovaasen and Schwerdtfeger 2011, 42; HHS
2014, Section I.B.16., 16).
,The following query was found in a patient's health record. Which of the answers best applies to this
query?
Dr. Bean: This patient was treated for both a primary neoplasm and a secondary neoplasm based on
documentation with the record. Was the focus of the treatment the secondary neoplasm?
a.This is a leading query
b.This query brings in information not documented within the chart and is inappropriate
c.This is a yes or no query
d.This is an appropriate query - CORRECT ANSWER-c If there is evidence of a diagnosis within the
medical record and the coder is uncertain whether it is a valid diagnosis because the documentation
is incomplete, it is the coder's responsibility to query the attending physician to determine if this
diagnosis should be included (Leon-Chisen 2013, 43-44).
An inpatient undergoes a procedure and has a postoperative complication during the
hospitalization. The insurance company will not pay for the entire amount requested. Which POA
indicator is likely part of the cause?
a.N
b.Y
c.W
d.U - CORRECT ANSWER-a The postoperative complication that is not present at admission. The
insurance company may not pay for the services provided to take care of the postoperative
complication (Garrett 2009, 11).
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 Status asthmaticus is defined as
continual wheezing in spite of therapy (Leon-Chisen 2013, 230).
Within the postoperative patient, this is the most common type of shock. It occurs when large
amounts of fluids are lost from hemorrhage or severe dehydration.
a.Cardiogenic
b.Renal
c.Hypovolemic
, d.Neurologic - CORRECT ANSWER-c Hypovolemic shock is the most common type of shock seen in
the postoperative patient. It occurs when large amounts of fluids are lost from hemorrhage or
severe dehydration (AHA 2011, 150).
The procedure that was performed for the definitive treatment (rather than the diagnosis) of the
main condition, or a complication of the condition is the:
a.Chief procedure
b.Principal treatment
c.Principal procedure
d.Comorbidity - CORRECT ANSWER-c The principal procedure is the procedure that was performed
for the definitive treatment (rather than the diagnosis) of the main condition or a complication of
the condition (Shaw and Carter 2014; LaTour et al. 2013, 432,940).
A physician query may not be appropriate in which of the following instances?
a.Diagnosis of viral pneumonia noted in the progress notes and sputum cultures showing
Haemophilus influenzae
b.Discharge summary indicates chronic renal failure but the progress notes document acute renal
failure throughout the stay
c.Acute respiratory failure in a patient whose lab report findings appear to not support this diagnosis
d.Diagnosis of chest pain and abnormal cardiac enzymes indicative of an AMI - CORRECT ANSWER-c
A query may not be appropriate because the clinical information or clinical picture does not appear
to support the documentation of a condition or procedure. In situations in which the provider's
documented diagnosis does not appear to be supported by clinical findings, a healthcare entity's
policies can provide guidance on a process for addressing the issue without querying the attending
physician (Shaw and Carter 2014; Schraffenberger and Kuehn 2011, 348).
Who is responsible for the content, quality, and signing of the discharge summary?
a.Attending physician
b.Head nurse
c.Consulting physician
d.Admitting nurse - CORRECT ANSWER-a The physician principally responsible for the patient's
hospital care generally dictates the discharge summary. However, a resident, physician assistant, or
nurse practitioner who is being supervised by the attending physician may complete this task.
Regardless of who documents it, the attending physician is responsible for the content and quality of
the summary and must date and sign it Shaw and Carter 2014; Fahrenholz and Russo 2013, 284).
