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AHIMA CDIP Exam Syllabus Topics:
| Section | Weight | Objectives |
|---|---|---|
| Compliance | - Regulatory compliance and ethical documentation practices - Audit readiness and documentation integrity standards | |
| Education and Leadership Development | 21–26% | - Provider education and interdisciplinary communication - CDI project development and physician engagement - CDI program leadership and organizational collaboration |
| Clinical Coding Practice | 15–18% | - Coding fundamentals and guidelines application - Diagnosis and procedure code assignment and sequencing - DRG assignment and reimbursement concepts |
| Record Review and Document Clarification | 24–28% | - Post-discharge review and documentation validation - Provider query development and compliance - Clinical documentation review and gap identification |
| CDI Metrics and Statistics | - Quality and outcome measurement (SOI/ROM) - Performance metrics and reporting |
AHIMA Certified Documentation Integrity Practitioner Sample Questions:
1. Which of the following is a clinical documentation integrity (CDI) financial impact measure?
A) Hierarchical condition category
B) Release of information
C) Severity of illness
D) Case mix index
2. What policies should query professionals follow?
A) CMS's policies related to querying
B) All healthcare entity's policies are the same
C) Their healthcare entity's internal policies related to querying
D) AHIMA's policies related to querying
3. A clinical documentation integrity practitioner (CDIP) is reviewing an outpatient surgical chart. The patient underwent a laparoscopic appendectomy for acute gangrenous appendicitis. Which coding reference should be used for coding advice on correct assignment of the procedure code for proper ambulatory payment classification (APC) reimbursement?
A) The Merck Manual
B) O ICD-10-CM/PCS Codebook
C) AHA Coding Clinic for ICD-10-CM/PCS
D) O AMA CPT Assistant
4. 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?
A) Involve the physician advisor/champion in addressing the medical staff's concerns
B) Refer the physician to the finance department to discuss required billing changes
C) Develop an administrative panel to oversee CDI process
D) Inform the physician that changes must be made
5. A noncompliant query includes querying the provider regarding
A) acute blood loss anemia due to low hemoglobin treated with iron supplements
B) sepsis that was present on admission because sepsis was only documented in the discharge summary
C) morbid obesity due to BMI of 40.9 documented on the history and physical
D) gram-negative pneumonia on every pneumonia case, regardless of documented clinical indicators
Solutions:
| Question # 1 Answer: D | Question # 2 Answer: C | Question # 3 Answer: D | Question # 4 Answer: A | Question # 5 Answer: D |
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