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AHIMA Certified Documentation Integrity Practitioner Sample Questions:

1. A 90-year-old female patient was admitted to emergency room c/o nausea and vomiting x2 days. Vital signs:
BP 130/72, P 86, R 22, T 99.8F, O2 sat 94% on room air. Patient has a history of cerebral vascular accident (CVA) and difficulty swallowing. CXR revealed right lower lobe infiltrate. Labs: WBC 12.0 with 71% segs. Physician documents patient with a history of CVA and difficulty swallowing. CXR revealed right lower lobe infiltrate, diagnosis: pneumonia.
Aspiration precautions and IV Clindamycin
ordered. Patient was discharged 3 days later with a diagnosis of pneumonia. Clarification is needed to determine which of the following is clinically indicated.

A) Simple pneumonia
B) Pneumonia, a sequela of CVA
C) Aspiration pneumonia
D) Complex pneumonia

2. A patient is admitted for pneumonia with a WBC of 20,000, respiratory rate 20, heart rate 85, and oral temperature 99.0°. On day 2, sputum cultures reveal positive results for pseudomonas bacteria. The most appropriate action is to

A) code pseudomonas pneumonia
B) query the provider to document the etiology of pneumonia
C) code pneumonia, unspecified
D) query the provider to see if pseudomonas sepsis is supported by the health record

3. The physician advisor/champion needs to provide ongoing education regarding coding and reimbursement regulations to the

A) organization's medical and surgical staff
B) Health Information Management coding staff
C) organization senior administration staff
D) clinical documentation integrity staff

4. Proposed changes to the inpatient prospective payment system (IPPS) take effect on

A) April 1
B) July 1
C) October 1
D) January 1

5. A patient presents to the emergency department for evaluation after suffering a head injury during a fall. A traumatic subdural hematoma is found on MRI, and the patient is taken directly to the operating room for evacuation. The neurosurgeon performs a burr hole procedure for evacuation of the subdural hematoma. The clot is removed successfully, and the patient is transferred to recovery in stable condition. Which is the correct current procedural terminology (CPT) code assignment for the procedure performed?

A) 61105 Twist drill hole subdural/ventricular puncture
B) 61108 Twist drill hole(s) for subdural, intracerebral, or ventricular puncture; for evacuation and/or drainage of subdural hematoma
C) 61154 Burr hole(s) with evacuation and/or drainage of hematoma, extradural or subdural
D) 61140 Burr hole(s) or trephine; with biopsy of brain or intracranial lesion

Solutions: