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AHIMA CDIP Exam Syllabus Topics:

SectionWeightObjectives
Topic 1: CDI Metrics & Statistics- Measure and Analyze CDI Performance
  • 1. Apply key CDI metrics
  • 2. Interpret documentation integrity data
Topic 2: Clinical Coding Practice15–18%- Coding Application and Resources
  • 1. Use reference resources for code assignment
  • 2. Understand DRG and coding conventions
  • 3. Assign and sequence diagnosis and procedure codes
Topic 3: Education and Leadership Development21–26%- Promote Documentation Integrity
  • 1. Support multidisciplinary team documentation efforts
  • 2. Develop and nurture collaborative relationships
  • 3. Promote CDI initiatives organization-wide
Topic 4: Record Review & Document Clarification- Review Clinical Records
  • 1. Identify documentation gaps and improvement areas
  • 2. Clarify clinical documentation with providers
Topic 5: Compliance- Regulatory and Compliance Fundamentals
  • 1. Understand documentation requirements and compliance
  • 2. Apply official guidelines (e.g., ICD-10-CM/PCS)

AHIMA Certified Documentation Integrity Practitioner Sample Questions:

1. A modifier may be used in CPT and/or HCPCS codes to indicate

A) a service or procedure was performed in its entirety
B) a service or procedure was performed by one provider
C) a service or procedure resulted in expected outcomes
D) a service or procedure was increased or reduced


2. 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) Productivity standards
B) Milestones
C) Mission
D) Review schedule


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) Assessment of CC/MCC capture rates
B) Comparison of risk of mortality with diagnostic related group capture rates
C) Assessment of APR-DRGs with capture of CC or MCC
D) Comparison of severity of illness with the CC capture rates


4. A query should be generated when the documentation is

A) legible
B) consistent
C) conflicting
D) complete


5. 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) Revise the query and send it back to the provider
B) Have a different CDIP query the provider
C) Record the query response as disagreed
D) Implement the department's escalation process


Solutions:

Question # 1
Answer: D
Question # 2
Answer: C
Question # 3
Answer: A
Question # 4
Answer: C
Question # 5
Answer: D

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