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AHIMA CDIP Exam Syllabus Topics:
| Section | Weight | Objectives |
|---|---|---|
| Topic 1: Compliance | 4–8% | - Fraud and abuse prevention - AHIMA standards and regulatory requirements - Compliance monitoring and reporting - Legal and ethical documentation practices |
| Topic 2: CDI Metrics & Statistics | 14–18% | - Benchmarking and reporting - Query response and volume tracking - Quality audits and compliance monitoring - DRG comparison and denial analysis |
| Topic 3: Research & Education | 11–15% | - Best practice research and implementation - Documentation improvement training materials - Provider and staff education - Regulatory and guideline updates |
| Topic 4: Leadership | 17–22% | - Provider engagement and communication - Policy and procedure creation - Interdisciplinary collaboration - CDI program development and promotion |
| Topic 5: Record Review & Document Clarification | 24–28% | - Compliance with query standards - Identify documentation gaps and specificity issues - POA, HAC, SOI, ROM clarification - Ethical provider query development - Query tracking and follow-up |
| Topic 6: Clinical Coding Practice | 22–26% | - DRG, CPT, and HCPCS code assignment - ICD-10-CM/PCS coding conventions and guidelines - Payer requirements and reimbursement models - Coding software and reference resources - Principal and secondary diagnosis identification |
AHIMA Certified Documentation Integrity Practitioner Sample Questions:
1. In order to best demonstrate the impact of clinical documentation on severity of illness and risk of mortality, which of the following examples is the most effective for physicians in a hospital?
A) Explanations on how severity of illness and risk of mortality impact reimbursement
B) Emphasize the Medicare requirements for documentation
C) Examples from the hospital's actual cases
D) The latest Medicare Provider and Analysis Review data
2. 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) Implement the department's escalation process
B) Revise the query and send it back to the provider
C) Record the query response as disagreed
D) Have a different CDIP query the provider
3. Creating policies and procedures for the query process will help eliminate
A) duplication
B) indecision
C) risk
D) confusion
4. Which of the following criteria for clinical documentation means the content of the record is trustworthy, safe, and yielding the same result when repeated?
A) Precise
B) Reliable
C) Legible
D) Complete
5. Which of the following should be shared to ensure a clear sense of what clinical documentation integrity (CDI) is and the CDI practitioner's role within the organization?
A) Mission
B) Milestones
C) Productivity standards
D) Review schedule
Solutions:
| Question # 1 Answer: C | Question # 2 Answer: A | Question # 3 Answer: D | Question # 4 Answer: B | Question # 5 Answer: A |
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