AHIMA CDIP Exam (page: 4)
AHIMA Certified Documentation Integrity Practitioner
Updated on: 25-Dec-2025

Viewing Page 4 of 29

A patient is admitted due to pneumonia. On day 1, a sputum culture is positive for pseudomonas bacteria. If the physician is queried and agrees that the patient has pseudomonas pneumonia, this specificity would:

  1. increase relative weight
  2. not meet medical necessity
  3. not increase relative weight
  4. meet medical necessity

Answer(s): D



Whether or not queries should be kept as a permanent part of the medical record is decided by

  1. federal law
  2. physician preference
  3. state law
  4. organizational policy

Answer(s): D



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?

  1. DRG 190 Chronic Obstructive Pulmonary Disease with MCC
  2. DRG 204 Respiratory Signs and Symptoms
  3. DRG 194 Simple Pneumonia and Pleurisy without CC/MCC
  4. DRG 202 Bronchitis and Asthma with CC-MCC

Answer(s): A



The ultimate purpose of clinical documentation integrity (CDI) expansion and growth is to

  1. provide community education to healthcare consumers
  2. show a direct relationship between clinical documentation and quality patient care
  3. create synergy between clinical education and CDI principles
  4. promote CDI functions so that physicians view the CDI staff as value-added service

Answer(s): B



Which of the following criteria for clinical documentation means the content of the record is trustworthy; sage, and yielding the same result when repeated?

  1. Complete
  2. Legible
  3. Precise
  4. Reliable

Answer(s): D



Viewing Page 4 of 29



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