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AHIMA CDIP Exam Syllabus Topics:
| Section | Weight | Objectives |
|---|---|---|
| Topic 1: Clinical Coding Practice | 22–26% | - Principal and secondary diagnosis identification - Coding software and reference resources - DRG, CPT, and HCPCS code assignment - Payer requirements and reimbursement models - ICD-10-CM/PCS coding conventions and guidelines |
| Topic 2: CDI Metrics & Statistics | 14–18% | - Query response and volume tracking - DRG comparison and denial analysis - Benchmarking and reporting - Quality audits and compliance monitoring |
| Topic 3: Research & Education | 11–15% | - Best practice research and implementation - Regulatory and guideline updates - Documentation improvement training materials - Provider and staff education |
| Topic 4: Leadership | 17–22% | - CDI program development and promotion - Provider engagement and communication - Policy and procedure creation - Interdisciplinary collaboration |
| Topic 5: Record Review & Document Clarification | 24–28% | - Identify documentation gaps and specificity issues - Ethical provider query development - Compliance with query standards - POA, HAC, SOI, ROM clarification - Query tracking and follow-up |
| Topic 6: Compliance | 4–8% | - Fraud and abuse prevention - Compliance monitoring and reporting - AHIMA standards and regulatory requirements - Legal and ethical documentation practices |
AHIMA Certified Documentation Integrity Practitioner Sample Questions:
1. A query should be generated when documentation contains a
A) diagnosis without clinical validation
B) problem list with symptoms related to the chief complaint
C) principal diagnosis without an MCC
D) postoperative hospital-acquired condition
2. An increase in claim denials has prompted a clinical documentation integrity (CDI) manager to engage the CDI physician advisor/champion in an effort to avoid future denials. How does this strategy impact the goal?
A) Clinicians will not require documentation integrity education.
B) Physicians will learn documentation integrity practices from peers.
C) Physicians can manage the documentation integrity process.
D) The CDI manager will exclusively provide education.
3. 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?
A) Allow physician responses via e-mail
B) Require the CDIP to call physicians to follow up
C) Provide education to physicians on query process
D) Update medical records with unsigned physician responses
4. 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) O ICD-10-CM/PCS Codebook
B) AHA Coding Clinic for ICD-10-CM/PCS
C) O AMA CPT Assistant
D) The Merck Manual
5. The clinical documentation integrity practitioner (CDIP) performed a verbal query and then later neglected following up with the provider. How should the CDIP avoid a compliance risk for this follow up failure according to AHIMA's Guidelines for Achieving a Compliant Query Practice?
A) Complete the documentation at the time of discussion or immediately following
B) Complete the documentation when there is a provider agreement
C) Complete the documentation immediately after the provider's response
D) Complete the documentation at the end of the day when entering cases reviewed
Solutions:
| Question # 1 Answer: A | Question # 2 Answer: B | Question # 3 Answer: C | Question # 4 Answer: C | Question # 5 Answer: A |
