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AHIMA CDIP Exam Syllabus Topics:

SectionWeightObjectives
CDI Metrics and Statistics- Performance metrics and reporting
- Quality and outcome measurement (SOI/ROM)
Record Review and Document Clarification24–28%- Post-discharge review and documentation validation
- Clinical documentation review and gap identification
- Provider query development and compliance
Education and Leadership Development21–26%- Provider education and interdisciplinary communication
- CDI project development and physician engagement
- CDI program leadership and organizational collaboration
Clinical Coding Practice15–18%- 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
Reveal Solution  Discussion  0

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
Reveal Solution  Discussion  0

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
Reveal Solution  Discussion  0

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
Reveal Solution  Discussion  0

Correct Answer: A  🗳️

Explanation: Only visible for ActualTestsIT members. You can sign-up / login (it's free).

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
Reveal Solution  Discussion  0

Correct Answer: A  🗳️

Explanation: Only visible for ActualTestsIT members. You can sign-up / login (it's free).

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