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AHIMA CDIP Exam Syllabus Topics:
| Section | Weight | Objectives |
|---|---|---|
| CDI Metrics and Statistics | - Performance metrics and reporting - Quality and outcome measurement (SOI/ROM) | |
| Record Review and Document Clarification | 24–28% | - Post-discharge review and documentation validation - Clinical documentation review and gap identification - Provider query development and compliance |
| 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% | - Diagnosis and procedure code assignment and sequencing - Coding fundamentals and guidelines application - DRG assignment and reimbursement concepts |
| Compliance | - Audit readiness and documentation integrity standards - Regulatory compliance and ethical documentation practices |
AHIMA Certified Documentation Integrity Practitioner Sample Questions:
A hospital clinical documentation integrity (CDI) director suspects physicians are over-using electronic copy and paste in patient records, a practice that increases the risk of fraudulent insurance billings. A documentation integrity project may be needed. What is the first step the CDI director should take?
- A. Gather data on the incidence of inaccurate record documentation
- B. Bring together a team of physicians and informatics specialists
- C. Recommend the physicians to be involved in the project
- D. Alert senior leadership to the record documentation problem
Correct Answer: A 🗳️
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A clinical documentation integrity (CDI) program that is compliant with regulations from the facility's payors results in
- A. less risk from audits
- B. higher overall program cost
- C. need for more CDI staff
- D. meeting external benchmarks
Correct Answer: A 🗳️
While reviewing a chart, a clinical documentation integrity practitioner (CDIP) needs to access the general rules for the ICD-10-CM Includes Notes and Excludes Notes
1 and 2. Which coding reference should be used?
- A. AMA CPT Assistant
- B. AHA Coding Clinic for ICD-10-CM
- C. ICD-10-CM Official Guidelines for Coding and Reporting
- D. Faye Brown's Coding Handbook
Correct Answer: C 🗳️
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Besides the physician advisor/champion, who should be included as a key stakeholder in the clinical documentation integrity (CDI) steering committee to promote CDI initiatives?
- A. Manager of HIM/Coding
- B. Director of Risk Management
- C. Manager of Surgical Services
- D. Director of Informatics
Correct Answer: A 🗳️
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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. Provide education to physicians on query process
- B. Require the CDIP to call physicians to follow up
- C. Allow physician responses via e-mail
- D. Update medical records with unsigned physician responses
Correct Answer: A 🗳️
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