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AHIMA CDIP Exam Syllabus Topics:
| Section | Weight | Objectives |
|---|---|---|
| Record Review & Document Clarification | 24–28% | - Ethical provider query development - Identify documentation gaps and specificity issues - POA, HAC, SOI, ROM clarification - Query tracking and follow-up - Compliance with query standards |
| Clinical Coding Practice | 22–26% | - Principal and secondary diagnosis identification - ICD-10-CM/PCS coding conventions and guidelines - DRG, CPT, and HCPCS code assignment - Coding software and reference resources - Payer requirements and reimbursement models |
| Leadership | 17–22% | - Policy and procedure creation - CDI program development and promotion - Provider engagement and communication - Interdisciplinary collaboration |
| Compliance | 4–8% | - Legal and ethical documentation practices - Compliance monitoring and reporting - AHIMA standards and regulatory requirements - Fraud and abuse prevention |
| Research & Education | 11–15% | - Best practice research and implementation - Provider and staff education - Documentation improvement training materials - Regulatory and guideline updates |
| CDI Metrics & Statistics | 14–18% | - DRG comparison and denial analysis - Quality audits and compliance monitoring - Benchmarking and reporting - Query response and volume tracking |
AHIMA Certified Documentation Integrity Practitioner Sample Questions:
A patient is admitted due to pneumonia. On day 1, a sputum culture is positive for psuedomonas bacteria. If the physician is queried and agrees that the patient has pseudomonas pneumonia, this specificity would
- A. not increase relative weight
- B. increase relative weight
- C. not meet medical necessity
- D. meet medical necessity
Correct Answer: B 🗳️
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Which of the following can be evidence of physician-hospital alignment?
- A. A low physician agreement rate
- B. A high physician response rate
- C. A high physician agreement rate
- D. A high clinical documentation integrity practitioner (CDIP) query rate
Correct Answer: C 🗳️
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The clinical documentation integrity (CDI) manager has noted a query response rate of 60%. The CDI practitioner reports that physicians often respond verbally to the query. What can be done to improve this rate?
- A. Permit CDI practitioners to document physician responses in the charts
- B. Require physicians to document responses in charts
- C. Have CDI manager teaming with coding supervisor to monitor physician responses
- D. Allow physician to respond via e-mail
Correct Answer: B 🗳️
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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?
- A. Coder and CDIP interaction
- B. Physician advisor/champion involvement
- C. Physician and CDIP interaction
- D. Executive oversight
Correct Answer: A 🗳️
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Which of the following diagnosis is MOST likely to trigger a second level review?
- A. Pneumonia
- B. Malnutrition
- C. Acute kidney injury
- D. Heart failure
Correct Answer: B 🗳️
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