2026 Valid CDIP Real Exam Questions, practice AHIMA CDI [Q60-Q83]

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2026 Valid CDIP Real Exam Questions, practice AHIMA CDI

Latest Success Metrics For Actual CDIP Exam (Updated 140 Questions)

NEW QUESTION 60
The clinical documentation integrity practitioner (CDIP) is reviewing tracking data and has noted physician responses are not captured in the medical chart. What can be done to improve this process?

Update medical records with unsigned physician responses

Allow physician responses via e-mail

Provide education to physicians on query process

Require the CDIP to call physicians to follow up

NEW QUESTION 61
A 100-year-old female presents to the emergency department with altered mental state and a 3-day history of productive cough, shortness of breath, and fever after a witnessed aspiration 3 days ago. The patient lives in custodial care at a nearby skilled nursing facility. Patient was treated with Augmentin at the facility without improvement. Exam is notable for Tc 38.9, blood pressure 142/78, respiratory rate 28, pulse 91. There is accessory muscle use with breathing.
Patient is moaning and disoriented but
otherwise the neurologic exam is nonfocal.
Labs notable for sodium 126, creatinine 0.5. white blood count 17.5, hemoglobin 13, platelet 200. venous blood gas 7.44/32/45/-3 Chest x-ray shows bilateral lower lobe infiltrates and dense right lower lobe consolidation.
Patient is placed on bilevel positive airway pressure and given vancomycin, pip/tazo, levofloxacin.
Discharge Diagnosis: health care associated pneumonia (HCAP), respiratory distress, altered mental status, low sodium Which list of diagnoses require a post-discharge query that will result in a more specific principal diagnosis with the highest level of severity of illness and risk of mortality?

Sepsis with acute hypoxemic respiratory failure, hyponatremia, pneumonia

Coma, stroke, HCAP, hypernatremia

Aspiration pneumonia, hyponatremia, septic encephalopathy, and sepsis with acute hypoxemic respiratory failure

Severe sepsis, hypernatremia, delirium, pneumonia

Explanation
A post-discharge query is needed to obtain a more specific principal diagnosis with the highest level of severity of illness (SOI) and risk of mortality (ROM) for this patient. The discharge diagnosis of health care associated pneumonia (HCAP) is not specific enough to capture the etiology, site, and severity of the pneumonia. Based on the clinical indicators in the case scenario, such as the history of aspiration, the chest x-ray findings, the elevated white blood count, the fever, and the antibiotic treatment, a more specific diagnosis of aspiration pneumonia would be appropriate. Aspiration pneumonia is a type of pneumonia that occurs when foreign material, such as food or vomit, is inhaled into the lungs, causing inflammation and infection. Aspiration pneumonia has a higher SOI and ROM than HCAP because it is associated with more complications and poorer outcomes 1.
Additionally, the discharge diagnosis of altered mental status is vague and does not reflect the underlying cause or severity of the condition. Based on the clinical indicators in the case scenario, such as the fever, the low sodium level, the moaning and disorientation, and the venous blood gas results, a more specific diagnosis of septic encephalopathy would be appropriate. Septic encephalopathy is a type of delirium that occurs when sepsis affects the brain function, causing confusion, agitation, or reduced consciousness. Septic encephalopathy has a higher SOI and ROM than altered mental status because it indicates a systemic inflammatory response and multi-organ dysfunction 2.
Furthermore, the discharge diagnosis of respiratory distress is also vague and does not reflect the underlying cause or severity of the condition. Based on the clinical indicators in the case scenario, such as the shortness of breath, the accessory muscle use, the respiratory rate, and the bilevel positive airway pressure treatment, a more specific diagnosis of acute hypoxemic respiratory failure would be appropriate. Acute hypoxemic respiratory failure is a type of respiratory failure that occurs when there is insufficient oxygen exchange in the lungs, causing low oxygen levels in the blood. Acute hypoxemic respiratory failure has a higher SOI and ROM than respiratory distress because it indicates a life-threatening condition that requires mechanical ventilation or oxygen therapy 3.
Finally, based on the clinical indicators in the case scenario, such as the fever, the elevated white blood count, and the antibiotic treatment, a diagnosis of sepsis should also be included in the query. Sepsis is a serious complication of infection that occurs when the body’s immune system overreacts to an infection and causes widespread inflammation and organ damage. Sepsis has a high SOI and ROM because it can lead to septic shock or death if not treated promptly 4.
Therefore, a post-discharge query should ask the provider to confirm or rule out aspiration pneumonia, hyponatremia (low sodium level), septic encephalopathy, and sepsis with acute hypoxemic respiratory failure as possible diagnoses for this patient. These diagnoses would result in a more specific principal diagnosis with the highest level of SOI and ROM for this patient.
References:
CDIP Exam Content Outline (https://www.ahima.org/media/1z0x0x1a/cdip-exam-content-outline.pdf) Aspiration Pneumonia – an overview | ScienceDirect Topics1 Septic Encephalopathy – an overview | ScienceDirect Topics2 Acute Hypoxemic Respiratory Failure – an overview | ScienceDirect Topics3 Sepsis – Symptoms and causes – Mayo Clinic4

NEW QUESTION 62
When queries are part of the health record, which of the following physician privilege could be suspended if the provider receives too many deficiencies due to incomplete records for failure to respond to queries?

Admitting

Consulting

Surgical

Credentialing

NEW QUESTION 63
Based on the flowchart below, at what point might the clinical documentation integrity practitioner (CDIP) enlist the help of the physician advisor/champion?

D – No retrospective query opportunity identified

H – Physician fails to respond tocquery

C – Retrospective query opportunity identified

E – Physician agrees with query and documents in MR

NEW QUESTION 64
The key component of the auditing and monitoring process to ensure provider query response is to

audit individual providers to indicate improvement in health record documentation

have a process in place for ongoing education and training of the staff involved in conducting provider queries

make sure that the language in the query is not leading or otherwise inappropriate

review queries retrospectively to ensure that they are completed according to documented Policies and procedures

NEW QUESTION 65
A pressure ulcer stage III is documented in the progress note. The clinical documentation integrity practitioner (CDIP) has queried the attending regarding the present on admission status of the pressure ulcer but has not received a response in an appropriate time frame. What should the CDIP do next?

Escalate issue to medical staff leadership

Query wound care nurse

Escalate issue to hospital administration

Query surgical consultant

NEW QUESTION 66
A key physician approaches the director of the coding department about the new emphasis associated with clinical documentation integrity (CDI). The physician does not support the program and believes the initiative will encourage inappropriate billing.
How should the director respond to the concerns?

Develop an administrative panel to oversee CDI process

Refer the physician to the finance department to discuss required billing changes

Involve the physician advisor/champion in addressing the medical staff’s concerns

Inform the physician that changes must be made

NEW QUESTION 67
A patient’s progress note states “The patient has chronic systolic heart failure”. After reviewing clinical indicators suggestive of an exacerbation of systolic heart failure, the clinical documentation integrity practitioner (CDIP) queries the physician to clarify the current acuity of the diagnosis. Which subsequent documentation in the health record suggests the provider did not understand the query?

The patient has chronic systolic heart failure.

The patient has acute on chronic systolic heart failure.

The patient did have an exacerbation of heart failure.

The patient has decompensated systolic heart failure.

NEW QUESTION 68
A clinical documentation integrity practitioner (CDIP) in an acute care hospital was asked to create new query templates for ICD-10 based on AHIMA and ACDIS guidelines. What should the multiple-choice query format include?

Clinically insignificant options

Impact on reimbursement

Clinically unsupported diagnosis

Clinically significant options

NEW QUESTION 69
A noncompliant query includes querying the provider regarding

acute blood loss anemia due to low hemoglobin treated with iron supplements

sepsis that was present on admission because sepsis was only documented in the discharge summary

gram-negative pneumonia on every pneumonia case, regardless of documented clinical indicators

morbid obesity due to BMI of 40.9 documented on the history and physical

NEW QUESTION 70
A clinical documentation integrity (CDI) program that is compliant with regulations from the facility’s payors results in

higher overall program cost

need for more CDI staff

less risk from audits

meeting external benchmarks

NEW QUESTION 71
Which of the following individuals should the clinical documentation integrity (CDI) manager consult when developing query policy and procedures?

Chief Medical Officer

Compliance Officer

CDI practitioner

Chief Financial Officer

NEW QUESTION 72
Which of the following committees should determine the chain of comnfand that will be used to manage physicians who are either unresponsive or uncooperative with the clinical documentation integrity (CDI) program?

Oversight

Communications

Operations

Compliance

NEW QUESTION 73
A 27-year-old male patient presents to the emergency room with crampy, right lower quadrant abdominal pain, a low-grade fever (101° Fahrenheit) and vomiting. The patient also has a history of type I diabetes mellitus. A complete blood count reveals mild leukocytosis (13,000/microliter). Abdominal ultrasound is ordered, and the patient is admitted for laparoscopic surgery. The patient is given an injection of neutral protamine Hagedorn insulin, in order to normalize the blood sugar level prior to surgery. Upon discharge, the attending physician documents “right lower quadrant abdominal pain due to possible acute appendicitis or probable Meckel diverticulitis”.
What is the proper sequencing of the principal and secondary diagnoses?

Right lower quadrant abdominal pain, acute appendicitis, Meckel diverticulitis, fever, vomiting, leukocytosis

Right lower quadrant abdominal pain, fever, vomiting, leukocytosis

Acute appendicitis, Meckel diverticulitis, type I diabetes mellitus

Acute appendicitis, right lower quadrant abdominal pain, type I diabetes mellitus

Explanation
The proper sequencing of the principal and secondary diagnoses in this case is as follows:
Principal diagnosis: Acute appendicitis. This is the condition, after study, that occasioned the admission to the hospital, according to the ICD-10-CM Official Guidelines for Coding and Reporting. The patient was admitted for laparoscopic surgery, which is a definitive treatment for acute appendicitis. The physician documented “possible acute appendicitis or probable Meckel diverticulitis” as the cause of the right lower quadrant abdominal pain. According to the AHA’s Coding Clinic, Fourth Quarter 2016, pp.
147-148, when a physician documents two diagnoses connected by “or”, coders should query the physician for clarification if possible. However, if a query is not possible or not answered, coders should assign codes for both conditions, unless one of them has been ruled out or confirmed by further testing or treatment. In this case, there is no indication that either acute appendicitis or Meckel diverticulitis has been ruled out or confirmed by further testing or treatment. Therefore, both conditions should be coded and reported. However, only one of them can be the principal diagnosis. Since acute appendicitis is more commonly associated with laparoscopic surgery than Meckel diverticulitis, and since it has a higher relative weight than Meckel diverticulitis under the MS-DRG system, it is reasonable to select acute appendicitis as the principal diagnosis 23.
Secondary diagnosis: Right lower quadrant abdominal pain. This is a sign or symptom that is associated with the principal diagnosis and requires clinical evaluation, therapeutic treatment, diagnostic procedures, extended length of hospital stay, or increased nursing care and/or monitoring. The patient presented with right lower quadrant abdominal pain as a manifestation of acute appendicitis or Meckel diverticulitis. The pain required clinical evaluation by abdominal ultrasound and therapeutic treatment by laparoscopic surgery. Therefore, it should be coded and reported as a secondary diagnosis 4.
Secondary diagnosis: Type I diabetes mellitus. This is a chronic condition that affects the patient’s care in terms of requiring diagnostic or therapeutic services or affecting patient outcomes or resource utilization. The patient has a history of type I diabetes mellitus and received an injection of neutral protamine Hagedorn insulin to normalize the blood sugar level prior to surgery. Therefore, it should be coded and reported as a secondary diagnosis 4.
References: 1: AHIMA CDIP Exam Prep, Fourth Edition, p. 133 2: ICD-10-CM Official Guidelines for Coding and Reporting FY 2021, Section II.A 3: AHA Coding Clinic for ICD-10-CM and ICD-10-PCS, Fourth Quarter 2016 4: ICD-10-CM Official Guidelines for Coding and Reporting FY 2021, Section III.C : AHIMA CDIP Exam Prep, Fourth Edition https://my.ahima.org/store/product?id=67077

NEW QUESTION 74
When there are comparative contrasting diagnoses supported by clinical criteria, the correct action is to

code the first condition listed

query for clarification

not code either diagnosis

code both diagnoses

NEW QUESTION 75
Yes/No queries may be used

when only the clinical indicators of a condition are present

to resolve conflicting documentation from multiple practitioners

when the diagnosis is not clearly documented in the health record

in any query format

NEW QUESTION 76
A hospital noticed a 30% denial rate in Medicare claims due to lack of clinical documentation, placing the hospital at risk of multiple Medicare violations. What step should the clinical documentation integrity (CDI) manager take to help avoid future Medicare violations?
Collaborate with physician advisor/champion and revenue cycle manager
Instruct the billing department to write off claims with insufficient documentation

Assign pre-billing claim review duties to physicians

Prevent submission of claims for improper documentation

NEW QUESTION 77
Which of the following is the definition of an Excludes 2 note in ICD-10-CM?

Neither of the codes can be assigned

Two codes can be used together to completely describe the condition

Only one code can be assigned to completely describe the condition

This is not a convention found in ICD-10-CM

NEW QUESTION 78
A patient was admitted with complaints of confusion, weakness, and slurred speech. A CT of the head and MRI were performed and resulted in normal findings. Daily aspirin was administered and a speech therapy evaluation was conducted. The final diagnosis on discharge was transient ischemic attack, and cerebrovascular disease was ruled out. What is the correct diagnostic related group assignment?

093 Other Disorders of Nervous System without CC/MCC

948 Signs and Symptoms without MCC

069 Transient Ischemia

066 Intracranial Hemorrhage or Cerebral Infarction without CC/MCC

NEW QUESTION 79
A hospital administrator wants to initiate a clinical documentation integrity (CDI) program and has developed a steering committee to identify performance metrics. The CDI manager expects to use a case mix index as one of the metrics. Which other metric will need to be measured?

Comparison of risk of mortality with diagnostic related group capture rates

Assessment of APR-DRGs with capture of CC or MCC

Comparison of severity of illness with the CC capture rates

Assessment of CC/MCC capture rates

NEW QUESTION 80
A 77-year-old male with chronic obstructive pulmonary disease (COPD) is admitted as an inpatient with severe shortness of breath. The patient is placed on oxygen at 2 liters per minute via nasal cannula. History reveals that the patient is on oxygen nightly at home. CXR is unremarkable. The most compliant query is

Patient has COPD, and is on nocturnal oxygen at home and is on continuous oxygen since admission.
Please order further tests so the patient’s severity of illness can be captured with the most accurate coding assignment.

Patient has COPD and is on oxygen every night at home and has been on continuous oxygen since admission, please document chronic respiratory failure, hypoxia, acute on chronic respiratory failure.

Patient has COPD, and is on nocturnal oxygen at home and is on continuous oxygen since admission.
Please indicate if you are treating one of these diagnoses: chronic respiratory failure, acute respiratory failure, acute on chronic respiratory failure, unable to determine, other.

Patient has COPD and is on oxygen every night at home and has been on continuous oxygen since admission. Based on these indications, please document chronic respiratory failure, acute respiratory failure, acute on chronic respiratory failure.

NEW QUESTION 81
The most beneficial step to identify post-discharge query opportunities that affect severity of illness, risk of mortality and case weight is to

look for documented conditions that have well supported accompanying clinical criteria

determine if only the treatment is documented and there is no diagnosis documented

watch for reportable conditions or conditions that are unambiguous or otherwise complete

identify normal diagnostic test results that may indicate a possible addition of a secondary diagnosis

NEW QUESTION 82
Which of the following sources provide external benchmarks to examine the effectiveness of a facility’s clinical documentation program?

Health Care Financing Administration

American Health Information Management Association

Agency for Healthcare Research and Quality

Medicare Provider Analysis and Review

NEW QUESTION 83
Collaboration between the physician advisor/champion and the clinical documentation integrity practitioners (CDIPs) would likely include

performing data analysis

developing query forms

educating physicians

querying physicians