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AHIMA CDIP Exam Syllabus Topics:
| Section | Weight | Objectives |
|---|---|---|
| Topic 1: Record Review and Document Clarification | 24–28% | - Post-discharge review and documentation validation - Clinical documentation review and gap identification - Provider query development and compliance |
| Topic 2: Education and Leadership Development | 21–26% | - Provider education and interdisciplinary communication - CDI program leadership and organizational collaboration - CDI project development and physician engagement |
| Topic 3: Clinical Coding Practice | 15–18% | - DRG assignment and reimbursement concepts - Diagnosis and procedure code assignment and sequencing - Coding fundamentals and guidelines application |
| Topic 4: CDI Metrics and Statistics | - Performance metrics and reporting - Quality and outcome measurement (SOI/ROM) | |
| Topic 5: Compliance | - Regulatory compliance and ethical documentation practices - Audit readiness and documentation integrity standards |
AHIMA Certified Documentation Integrity Practitioner Sample Questions:
1. Which of the following organizations should a clinical documentation integrity practitioner (CDIP) monitor?
A) Program for Evaluating Payment Patterns Electronic Report (PEPPER), Recovery Auditors (RAs), Center for Improvement in Healthcare (CIHQ)
B) Center for Improvement in Healthcare (CIHQ), Accreditation Commission for Healthcare (ACHC), Recovery Auditors (RAs)
C) Office of Inspector General (OIG), Accreditation Commission for Healthcare (ACHC), Recovery Auditors (RAs)
D) Recovery Auditors (RAs), Program for Evaluating Payment Patterns Electronic Report (PEPPER), Office of Inspector General (OIG)
2. 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) Develop an administrative panel to oversee CDI process
B) Refer the physician to the finance department to discuss required billing changes
C) Involve the physician advisor/champion in addressing the medical staff's concerns
D) Inform the physician that changes must be made
3. 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?
A) Comparison of severity of illness with the CC capture rates
B) Comparison of risk of mortality with diagnostic related group capture rates
C) Assessment of CC/MCC capture rates
D) Assessment of APR-DRGs with capture of CC or MCC
4. What policies should query professionals follow?
A) AHIMA's policies related to querying
B) All healthcare entity's policies are the same
C) CMS's policies related to querying
D) Their healthcare entity's internal policies related to querying
5. A 50-year-old male patient was admitted with complaint of 3-day history of shortness of breath. Vital signs:
BP 165/90, P 90, T 99.9.F, O2 sat 95% on room air. Patient
has history of asthma, chronic obstructive pulmonary disease (COPD), and hypertension (HTN). His medicines are Albuterol and Norvasc. CXR showed chronic lung disease and left lower lobe infiltrate. Labs: WBC 9.5 with 65% segs. Physician documented that patient has asthma flair and admitted with decompensated COPD, ordered IV steroids, O2 at 2L/min via nasal cannula, Albuterol inhalers 4x per day, and Clindamycin. Patient improved and was discharged 3 days later. Which action would have the highest impact on the patient's severity of illness (SOI) and risk of mortality (ROM)?
A) Query the physician to clarify if patient has acute COPD exacerbation.
B) Query the physician to clarify for clinical significance of the CXR results.
C) Query the physician to clarify for type of COPD such as severe asthma.
D) Query the physician to clarify if CXR result means patient has pneumonia.
Solutions:
| Question # 1 Answer: D | Question # 2 Answer: C | Question # 3 Answer: C | Question # 4 Answer: D | Question # 5 Answer: D |


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