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AHIMA CDIP Exam Syllabus Topics:
| Section | Weight | Objectives |
|---|---|---|
| Topic 1: CDI Metrics & Statistics | 14–18% | - Quality audits and compliance monitoring - DRG comparison and denial analysis - Benchmarking and reporting - Query response and volume tracking |
| Topic 2: Clinical Coding Practice | 22–26% | - DRG, CPT, and HCPCS code assignment - Principal and secondary diagnosis identification - Payer requirements and reimbursement models - ICD-10-CM/PCS coding conventions and guidelines - Coding software and reference resources |
| Topic 3: Compliance | 4–8% | - Fraud and abuse prevention - Compliance monitoring and reporting - AHIMA standards and regulatory requirements - Legal and ethical documentation practices |
| Topic 4: Research & Education | 11–15% | - Provider and staff education - Documentation improvement training materials - Best practice research and implementation - Regulatory and guideline updates |
| Topic 5: Record Review & Document Clarification | 24–28% | - Identify documentation gaps and specificity issues - Query tracking and follow-up - Compliance with query standards - Ethical provider query development - POA, HAC, SOI, ROM clarification |
| Topic 6: Leadership | 17–22% | - Interdisciplinary collaboration - Provider engagement and communication - Policy and procedure creation - CDI program development and promotion |
AHIMA Certified Documentation Integrity Practitioner Sample Questions:
An 86-year-old female is brought to the emergency department by her daughter. The patient complains of feeling tired, weak and excessive sleeping. The patient's daughter comments that patient's mental condition has not been the same. Lab results are unremarkable except for a sodium level of 119, a BUN of 22, and a creatinine of 1.35. The patient receives normal saline IV infusing at 100 cc/hr. The admitting diagnosis is weakness, altered mental status and dehydration. Which of the following queries is presented in an ethical manner thus avoiding potential fraud and/or compliance issues?
- A. Patient is feeling tired, weak, sleeping a lot and has altered mental status. Sodium is 119 and she is on NS IV at 100 cc/hr. Is the altered mental status related to the sodium of 119?
- B. Patient's sodium is 119 and she is on NS IV at 100 cc/hr, is this clinically significant? If so, please document a corresponding diagnosis related to this lab result.
- C. Patient's sodium is 119 and she is on NS IV at 100 cc/hr, does patient have hyponatremia?
- D. Patient is feeling tired, weak, sleeping a lot and has altered mental status. Sodium is 119 and she is on NS IV at 100 cc/hr, please clarify the clinical significance of the lab result.
Correct Answer: D 🗳️
A clinical documentation integrity practitioner (CDIP) must determine the present on admission (POA) status of a stage IV sacral decubitus ulcer documented in the discharge summary. What is the first step that should be taken?
- A. Query the attending provider
- B. Read the nursing admission notes
- C. Look for wound care documentation
- D. Review the history and physical
Correct Answer: D 🗳️
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The provider was queried because the patient met clinical criteria for acute hypoxic respiratory failure. The response to the query was different than what was expected by the clinical documentation integrity practitioner (CDIP). What should the CDIP do?
- A. Record the query response as disagreed
- B. Implement the department's escalation process
- C. Revise the query and send it back to the provider
- D. Have a different CDIP query the provider
Correct Answer: B 🗳️
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Based on the flowchart below, at what point might the clinical documentation integrity practitioner (CDIP) enlist the help of the physician advisor/champion?
- A. E - Physician agrees with query and documents in MR
- B. D - No retrospective query opportunity identified
- C. H - Physician fails to respond tocquery
- D. C - Retrospective query opportunity identified
Correct Answer: C 🗳️
The facility has received a clinical validation denial for sepsis. The denial states sepsis is not a clinically valid diagnosis because it does not meet Sepsis-3 criteria. The facility has a policy stating it uses Sepsis-2 criteria.
What is the BEST next step?
- A. Remove sepsis from all claims where the diagnosis is not supported by sepsis 3 criteria.
- B. Appeal the denial because all payors must use the hospital's sepsis criteria when reviewing their claims.
- C. Query physicians when Sepsis-3 criteria is not met so they can provide additional documentation to support the diagnosis.
- D. Have the contracting department work with payors to obtain agreement on how sepsis will be clinically validated.
Correct Answer: D 🗳️
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