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AHIMA Certified Documentation Integrity Practitioner Sample Questions:

1. A physician documented the specific site of the malignancy in the medical record documentation; however, the coder is unable to locate a specific entry in the ICD-10- CM Alphabetical Index to match the specified diagnosis. Which abbreviation used in the Alphabetical Index will assist the coder in assigning the appropriate diagnosis code for the specified condition?

A) OCE
B) NEC
C) NOS
D) DRG

2. A patient was admitted due to possible pneumonia. Chest x-ray was positive for infiltrate. The physician's documentation indicates that the patient continues to smoke cigarettes despite recommendations to quit. Patient also has a long-term history of chronic obstructive pulmonary disease (COPD) due to smoking. IV antibiotic was given for pneumonia along with oral Prednisone and Albuterol for COPD.
Discharge diagnoses:
1. Pneumonia
2. COPD
3. Current smoker
What is the correct diagnostic related group assignment?

A) DRG 202 Bronchitis and Asthma with CC/MCC
B) DRG 190 Chronic Obstructive Pulmonary Disease with MCC
C) DRG 194 Simple Pneumonia and Pleurisy without CC/MCC
D) DRG 204 Respiratory Signs and Symptoms

3. What type of query may NOT be used in circumstances where only clinical indicators of a condition are present, and the condition/diagnosis has not been documented in the health record?

A) Yes/No
B) Open-ended
C) Multiple-choice
D) Verbal

4. What is the term used when a patient is entered in the Master Patient Index (MPI) multiple times, in different ways, resulting in multiple medical record numbers?

A) Overlap
B) Facsimile
C) Replica
D) Clone

5. When there are comparative contrasting diagnoses supported by clinical criteria, the correct action is to

A) query for clarification
B) code both diagnoses
C) code the first condition listed
D) not code either diagnosis

Solutions: