18 free AHIMA CDIP Certified Documentation Integrity Practitioner practice questions from the CertStash pack of 140, each with the correct answer and a full explanation. The rule is the same for every exam: ten free on the product page, 18 free here, all 140 in the pack, and each step includes the one before it.
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Question 1
An increase in claim denials has prompted a clinical documentation integrity (CDI) manager to engage the CDI physician advisor/champion in an effort to avoid future denials.
How does this strategy impact the goal?
Show answer and explanation
Correct answer: C. Physicians will learn documentation integrity practices from peers.
A physician advisor/champion is a practicing physician who speaks the same clinical language as the medical staff, so providers tend to accept documentation feedback more readily from a peer than from nonphysician staff. Engaging the advisor to address denials turns lessons from denied claims into peer-to-peer education on documentation integrity practices, such as documenting the clinical support for each diagnosis. That peer learning is what moves the program toward its goal of preventing future denials, while the CDI team continues to run the program and provide its own education alongside the advisor.
Why the other options are wrong
- A. Peer involvement adds to provider education; it does not remove the need for documentation integrity education.
- B. The physician advisor supports the CDI program, but physicians do not take over management of the documentation integrity process.
- D. Bringing in the physician advisor broadens who educates providers, so the CDI manager is no longer the only educator.
Question 2
A clinical documentation integrity practitioner (CDIP) generates a concurrent query and continues to follow retrospectively; however, the coder releases the bill before the query is answered. The CDIP wonders if it is appropriate to re-bill the account if the physician answers the query after the bill has dropped.
Which policy should the hospital follow to avoid a compliance risk?
Show answer and explanation
Correct answer: A. A rebilling is permissible when queries are answered after the initial bill.
A query answered after the claim has dropped can still change the coded data, and the AHIMA/ACDIS query practice guidelines expect organizations to have a policy covering post-bill queries and rebilling. When the provider's late response adds documentation that is clinically supported and changes code assignment, the account can be corrected and rebilled within the payer's rules. A written policy that permits rebilling in this situation, applied consistently, keeps the claim aligned with the final record and avoids the compliance risk of knowingly leaving an inaccurate claim in place or handling late responses case by case.
Why the other options are wrong
- B. How often post-bill queries arise from audits does not tell the hospital how to handle a late query response.
- C. Post-bill queries are an accepted way to correct documentation issues found during audits.
- D. A corrected claim is the proper way to fix an incomplete or inaccurate first bill, not something to avoid.
Question 3
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:
Show answer and explanation
Correct answer: D. query the provider to document the etiology of pneumonia
A coder cannot assign an organism-specific pneumonia code from a culture result alone, because abnormal laboratory findings are coded only when the provider documents their clinical significance. The positive sputum culture for Pseudomonas, together with the pneumonia diagnosis, is a clear clinical indicator that the documentation is incomplete, so the right step is a compliant query asking the provider to document the etiology of the pneumonia. The provider can then confirm, rule out or leave undetermined the causative organism, and the final code reflects the provider's own clinical judgment rather than an assumption drawn from the lab report.
Why the other options are wrong
- A. Coding unspecified pneumonia ignores a clear clinical indicator that a more specific diagnosis may be supported.
- B. Apart from the elevated white count, the vital signs give little support for sepsis, so a sepsis query lacks clinical indicators.
- C. The organism cannot be coded from the culture report without the provider documenting the link to the pneumonia.
Question 4
Which of the following can be evidence of physician-hospital alignment?
Show answer and explanation
Correct answer: C. A high physician response rate
Physician-hospital alignment shows up as physicians actively participating in the hospital's documentation integrity effort, and the response rate measures exactly that: the share of queries that providers answer. A high response rate means physicians are engaging with CDI staff and taking part in the shared goal of a complete and accurate record. Agreement is a different matter, since a compliant query must allow any clinically supported answer, including disagreement or unable to determine. Agreement rates therefore reflect clinical judgment and query quality more than alignment, and a CDI query rate measures the CDI staff's activity rather than physician engagement.
Why the other options are wrong
- A. The query rate measures how often CDI staff query, not how engaged physicians are.
- B. Agreement depends on clinical judgment and query quality, and providers must remain free to disagree, so it is not the measure of alignment.
- D. A low agreement rate signals possible problems with query quality or clinical support, not alignment.
Question 5
When a change in departmental workflow is necessary, the first step is to
Show answer and explanation
Correct answer: B. assess the current workflow
Any workflow change starts with an assessment of how the work is done today. Mapping the current workflow establishes a baseline, shows where delays, duplication or gaps occur, and gives the measurements needed later to prove the change worked. Only after that assessment can the team define gaps and solutions, redesign the process and set timelines. Skipping the assessment risks fixing the wrong problem or disrupting steps that were working well, which is why it comes first in any structured change effort.
Why the other options are wrong
- A. Re-engineering the process comes after the current state is understood and the gaps are defined.
- C. Gaps and solutions can only be defined once the current workflow has been assessed.
- D. Timelines are set during implementation planning, after assessment and redesign decisions.
Question 6
The third quarter target concurrent physician query response rate for each physician in a hospital gastroenterology department was 80%. Nine physicians met or exceeded this metric; however, two physicians had third quarter concurrent physician query response rates of 19% and 64%.
What is the best course of action for the clinical documentation integrity (CDI) physician advisor/champion?
Show answer and explanation
Correct answer: B. Schedule individual meetings with each low-performing physician
Nine of the eleven physicians met the 80% target, so the problem is limited to two individuals. The most effective and respectful response is targeted, one-on-one follow-up: the physician advisor/champion meets privately with each low-performing physician to review the response rate, understand barriers such as workload or confusion about the query process, and agree on improvement steps. Peer-to-peer conversation from the physician advisor tends to carry weight, and handling it individually avoids burdening or embarrassing the physicians who are already meeting the expectation.
Why the other options are wrong
- A. Going to the department chair first escalates before the advisor has tried direct peer follow-up with the two physicians.
- C. A group meeting spends the time of nine compliant physicians on a problem limited to two.
- D. Meeting every physician individually is inefficient when only two missed the target.
Question 7
Patient is admitted with oliguria, pulmonary edema, and dehydration. Labs are remarkable for an elevated creatinine of 2.4, with a baseline of 1.1.
Patient was hydrated for 48 hours with drop in creatinine.
What would the appropriate action be?
Show answer and explanation
Correct answer: C. Query the physician to see if acute renal failure is clinically supported
The record shows clinical indicators of an acute kidney problem: oliguria and a creatinine of 2.4 against a baseline of 1.1, more than double the baseline. No diagnosis explaining these findings is documented, so a query asking whether acute renal failure is clinically supported is appropriate. The query should go no further than the indicators allow. The creatinine fell after 48 hours of hydration, a course that fits a prerenal cause from dehydration, and nothing in the record points to tubular necrosis, so asking about acute tubular necrosis would introduce a diagnosis the record does not support.
Why the other options are wrong
- A. Dehydration does not explain away a creatinine more than double baseline with oliguria; the indicators still warrant a query.
- B. Diagnoses cannot be coded from symptoms and lab values; the provider must document acute renal failure.
- D. Nothing in the record indicates tubular necrosis, and the rapid improvement with fluids argues against it.
Question 8
A noncompliant query includes querying the provider regarding:
Show answer and explanation
Correct answer: A. gram-negative pneumonia on every pneumonia case, regardless of documented clinical indicators
Every compliant query must be driven by clinical indicators found in the individual patient's record. Querying for gram-negative pneumonia on every pneumonia case, regardless of what the record shows, is a blanket query aimed at a higher-paying diagnosis rather than at clarifying documentation, so it is noncompliant. The other scenarios each rest on specific documentation: a recorded BMI that may support a weight diagnosis, a low hemoglobin with treatment that may point to a more specific anemia, and a sepsis diagnosis whose present-on-admission status is unclear because it appears only in the discharge summary.
Why the other options are wrong
- B. A documented BMI of 40.9 is a patient-specific clinical indicator that supports a query about the associated weight diagnosis.
- C. A low hemoglobin that is being treated is a valid clinical indicator for clarifying the type of anemia.
- D. Clarifying present-on-admission status when sepsis appears only in the discharge summary is a legitimate query.
Question 9
When there is a discrepancy between the clinical documentation integrity practitioner’s (CDIP’s) working DRG and the coder’s final DRG, which of the following is considered a fundamental element that must be in place for a successful resolution?
Show answer and explanation
Correct answer: B. Coder and CDIP interaction
A difference between the CDI working DRG and the coder's final DRG is resolved through a reconciliation process, and its foundation is direct interaction between the coder and the CDI practitioner. Together they compare the diagnoses and procedures each captured, review the documentation and coding guidelines behind each choice, and agree on the final assignment or decide that a query is needed. Physician advisor or executive involvement is an escalation step for disagreements the two cannot settle, not the basic element that must be in place for reconciliation to work.
Why the other options are wrong
- A. The physician is consulted through queries, but the discrepancy itself is reconciled between CDI and coding.
- C. The physician advisor serves as an escalation point when coding and CDI cannot agree, not as the first step.
- D. Executive oversight supports the program but is not the working element that resolves individual DRG differences.
Question 10
A patient presented with shortness of breath, elevated B-type natriuretic peptide, and lower extremity edema to the emergency room. During the hospitalization, a cardiac echocardiogram was performed and revealed an ejection fraction of 55% with diastolic dysfunction. The patient's history includes hypertension (HTN), chronic kidney disease (CKD) (baseline glomerular filtration rate 40) and congestive heart failure (CHF). The clinical documentation integrity practitioner (CDIP) has queried the physician to further clarify the patient’s diagnosis.
Which response provides the highest level of specificity?
Show answer and explanation
Correct answer: C. Acute on chronic diastolic CHF with hypertensive renal disease, CKD 3
The ejection fraction of 55% with diastolic dysfunction points to diastolic heart failure, the history of congestive heart failure makes the condition chronic, and the new shortness of breath, elevated BNP and edema show an acute decompensation, so acute on chronic diastolic heart failure is the most specific description. ICD-10-CM also presumes a causal link between hypertension and chronic kidney disease, so naming hypertensive renal disease with CKD stage 3 (consistent with a GFR of 40) captures the full picture. This response specifies the correct acuity and type together with the hypertensive relationship, which no other option does.
Why the other options are wrong
- A. It omits the type of heart failure and the chronic component.
- B. It leaves out the chronic component and lists hypertension and CKD without their hypertensive relationship.
- D. A preserved ejection fraction of 55% with diastolic dysfunction does not support systolic heart failure.
Question 11
Several physicians at a local hospital are having difficulty providing adequate documentation on patients admitted with a diagnosis of pneumonia with or without clinical indications of gram-negative pneumonia. Subsequently, clinical documentation integrity practitioners (CDIPs) are altering health records.
Which policy and procedure should be developed to ensure compliant practice?
Show answer and explanation
Correct answer: D. Professional ethical standards
CDI practitioners altering health records is a breach of professional ethics. The health record must reflect the provider's own documentation, and CDI staff clarify that documentation only through compliant queries; they never change, add to or remove what a provider has written. A policy and procedure grounded in professional ethical standards, such as the AHIMA Code of Ethics and the AHIMA Standards of Ethical Coding, sets out these expectations, defines integrity of the record as a core duty and gives the organization a basis for addressing violations. Documentation difficulties among physicians are handled with education and queries, not by staff editing the record.
Why the other options are wrong
- A. Performance standards measure productivity and quality of work, not the ethics of altering records.
- B. Quality improvement standards address processes and outcomes, not the misconduct of changing health records.
- C. Accreditation standards come from outside bodies and do not serve as the internal policy governing staff conduct.
Question 12
An otherwise healthy male was admitted to undergo a total hip replacement as treatment for ongoing primary osteoarthritis of the right hip.
During the post-operative period, the patient choked on liquids which resulted in aspiration pneumonia as shown on chest x-ray. Intravenous antibiotics were administered, and the pneumonia was monitored for improvement with two additional chest x-rays. The patient was discharged to home in stable condition on post-operative day 5.
Final Diagnoses:
1. Primary osteoarthritis of right hip status post uncomplicated total hip replacement
2. Aspiration pneumonia due to choking on liquid episode
What is the correct diagnostic related group assignment?
Show answer and explanation
Correct answer: D. 469 Major Joint Replacement or Reattachment of Lower Extremity with MCC
The patient was admitted for a total hip replacement to treat primary osteoarthritis, so the osteoarthritis is the principal diagnosis and the hip replacement is a major joint replacement procedure. That procedure drives the case into the surgical DRGs for major joint replacement or reattachment of lower extremity. The aspiration pneumonia that developed after surgery was treated with intravenous antibiotics and monitored with repeat chest x-rays, so it is reported as a secondary diagnosis, and aspiration pneumonia is an MCC. The case therefore groups to MS-DRG 469, Major Joint Replacement or Reattachment of Lower Extremity with MCC.
Why the other options are wrong
- A. A major joint replacement moves the case into a surgical DRG, not the medical bone diseases and arthropathies DRG.
- B. The pneumonia arose after admission and is a secondary diagnosis, not the principal diagnosis.
- C. The aspiration pneumonia is an MCC, so the without MCC DRG does not apply.
Question 13
Besides the physician advisor/champion, who should be included as a key stakeholder in the clinical documentation integrity (CDI) steering committee to promote CDI initiatives?
Show answer and explanation
Correct answer: C. Manager of HIM/Coding
CDI and coding depend on each other: CDI clarifies the documentation, and HIM/coding turns it into the final coded data that drives DRG assignment, quality reporting and reimbursement. The manager of HIM/Coding is therefore a key stakeholder on the CDI steering committee alongside the physician advisor/champion. That role brings knowledge of coding guidelines, DRG reconciliation, query workflow and record completion, and ensures that CDI initiatives and coding practice stay aligned across the organization.
Why the other options are wrong
- A. Risk management has a narrower interest and is not central to CDI initiatives.
- B. Surgical services is a single department, not a core stakeholder for an organization-wide CDI program.
- D. Informatics may support CDI tools, but it is not the core partner in documentation and coding integrity.
Question 14
A clinical documentation integrity (CDI) program that is compliant with regulations from the facility’s payors results in
Show answer and explanation
Correct answer: A. meeting external benchmarks
A CDI program that follows the regulations of the facility's payers produces documentation and coded data built on the same rules that payers, regulators and peer facilities apply. Because diagnoses are clinically supported, queries are compliant and codes follow the Official Guidelines, the program's results, such as case mix index, CC and MCC capture and denial rates, can be validly compared with external figures and line up with them. Compliance with payer regulations therefore results in a program that meets the external benchmarks used to judge CDI performance across organizations.
Why the other options are wrong
- B. Payers select records for audit from data patterns and review programs, so a compliant program remains subject to audits and the result described is benchmark performance.
- C. Compliance with payer regulations does not by itself create a need for more CDI staff.
- D. Following payer regulations does not by itself drive overall program cost higher.
Question 15
A clinical documentation integrity practitioner (CDIP) hired by an internal medicine clinic is creating policies governing written queries.
What is an AHIMA best practice for these policies?
Show answer and explanation
Correct answer: C. Queries are limited to non-leading questions
The core principle of the AHIMA/ACDIS guidance on compliant query practice is that queries must not lead the provider. A query should present the relevant clinical indicators and allow any clinically supported answer, without suggesting a preferred diagnosis, mentioning financial impact or indicating that one response is expected. Writing this requirement into the clinic's written query policy protects both the providers' independent clinical judgment and the integrity of the coded data, and it applies regardless of setting or query format.
Why the other options are wrong
- A. Requiring answers from one group of physicians is not an AHIMA best practice; policies address all providers and escalation for non-response.
- B. Disciplining non-response is a matter for medical staff rules, not an AHIMA query best practice.
- D. Illegible documentation is a recognized reason to query, not a case where queries are unnecessary.
Question 16
A 50-year-old with a history of stage II lung cancer is brought to the emergency department with severe dyspnea. The patient underwent the last round of chemotherapy 3 days ago. Vital signs reveal a temperature of 98.4, a heart rate of 98, a respiratory rate of 28, and a blood pressure of 124/82. O2 saturation on room air is 92%. The patient is 5’5” and weighs 98 lbs. The registered dietitian notes the patient is malnourished with BMI of 19. Chest x-ray reveals a large pleural effusion in the right lung. Thoracentesis is performed and 1000 cc serosanguineous fluid is removed.
The admitting diagnosis is large right lung pleural effusion related to lung cancer stage II, documented multiple times.
What post discharge query opportunity should be sent to the physician that will affect severity of illness (SOI)/risk of mortality (ROM)?
Show answer and explanation
Correct answer: B. Query for a diagnosis associated with the dietician’s finding of malnutrition
The registered dietitian has assessed the patient as malnourished, but the attending physician has not documented a corresponding diagnosis, and codes cannot be assigned from a dietitian's assessment alone. Malnutrition is a secondary diagnosis that raises severity of illness and risk of mortality, so a post-discharge query is warranted. A compliant query presents the dietitian's finding, the weight and the BMI and asks the physician to document any associated diagnosis, leaving room for clinically supported options, other and unable to determine. The pleural effusion is already documented as related to the lung cancer, so it offers no comparable opportunity.
Why the other options are wrong
- A. The effusion is already documented as related to the lung cancer, so a query for malignant pleural effusion adds little.
- C. The reason for admission is already clearly documented as the pleural effusion related to lung cancer.
- D. Asking the physician to document one named diagnosis is leading; the query should seek the associated diagnosis with appropriate options.
Question 17
A patient falls off a ladder and undergoes a right femur procedure. Three weeks later, the patient returns to the hospital for removal of the external fixation device. The ICD-10-CM 7th character code value should indicate
Show answer and explanation
Correct answer: D. subsequent
For injuries, ICD-10-CM uses the 7th character to show the phase of care. Initial applies while the patient receives active treatment, and subsequent applies once active treatment is complete and the patient is in the healing or recovery phase. The Official Guidelines list removal of an external or internal fixation device among the encounters coded as subsequent for a fracture. Aftercare Z codes are not used for injuries, because the 7th character already identifies subsequent care.
Why the other options are wrong
- A. Initial is for active treatment of the fracture, which ended with the original procedure.
- B. Sequela is for complications or conditions that result as a late effect of the injury, not routine device removal.
- C. Aftercare is not a 7th character value, and aftercare Z codes are not used for injuries with 7th characters.
Question 18
The clinical documentation integrity practitioner (CDIP) performed a verbal query and then later neglected following up with the provider.
How should the CDIP avoid a compliance risk for this follow up failure according to AHIMA’s Guidelines for Achieving a Compliant Query Practice?
Show answer and explanation
Correct answer: D. Complete the documentation immediately after the provider’s response
The AHIMA/ACDIS Guidelines for Achieving a Compliant Query Practice require verbal queries to be documented like written ones, including the clinical indicators presented, the question asked and the provider's response. Completing that documentation immediately after the provider responds captures the whole exchange while it is fresh, creates a record of the query and its outcome that can be tracked and retained, and shows whether the provider still needs to document the answer in the health record. Recording it at once, rather than at a later convenient point, prevents the follow-up from being lost.
Why the other options are wrong
- A. Documentation completed while the discussion is still under way may not yet include the provider's answer, which the record of a verbal query must capture.
- B. Documenting only when the provider agrees would leave disagreements and other responses unrecorded.
- C. Waiting until the end of the day risks lost details and missed follow-up.
That was 18 of 140.
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