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AHIMA CDIP Exam Syllabus Topics:
| Section | Weight | Objectives |
|---|---|---|
| Clinical Coding Practice | 22–26% | - Coding software and reference resources - Payer requirements and reimbursement models - Principal and secondary diagnosis identification - DRG, CPT, and HCPCS code assignment - ICD-10-CM/PCS coding conventions and guidelines |
| Compliance | 4–8% | - AHIMA standards and regulatory requirements - Compliance monitoring and reporting - Fraud and abuse prevention - Legal and ethical documentation practices |
| Record Review & Document Clarification | 24–28% | - Ethical provider query development - POA, HAC, SOI, ROM clarification - Identify documentation gaps and specificity issues - Query tracking and follow-up - Compliance with query standards |
| Leadership | 17–22% | - Provider engagement and communication - Interdisciplinary collaboration - Policy and procedure creation - CDI program development and promotion |
| Research & Education | 11–15% | - Regulatory and guideline updates - Best practice research and implementation - Provider and staff education - Documentation improvement training materials |
| CDI Metrics & Statistics | 14–18% | - Benchmarking and reporting - Quality audits and compliance monitoring - DRG comparison and denial analysis - Query response and volume tracking |
AHIMA Certified Documentation Integrity Practitioner Sample Questions:
Automated registration entries that generate erroneous patient identification-possibly leading to patient safety and quality of care issues, enabling fraudulent activity involving patient identity theft, or providing unjustified care for profit-is an example of a potential breach of:
- A. Auditing integrity
- B. Patient identification and demographic accuracy
- C. Authorship integrity
- D. Documentation integrity
Correct Answer: B 🗳️
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A modifier may be used in CPT and/or HCPCS codes to indicate
- A. a service or procedure resulted in expected outcomes
- B. a service or procedure was performed by one provider
- C. a service or procedure was performed in its entirety
- D. a service or procedure was increased or reduced
Correct Answer: D 🗳️
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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. Have a different CDIP query the provider
- B. Implement the department's escalation process
- C. Record the query response as disagreed
- D. Revise the query and send it back to the provider
Correct Answer: B 🗳️
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The BEST place for the provider to document a query response is which of the following?
- A. The next progress note and all subsequent notes including the discharge summary
- B. The query form
- C. An addendum to the history and physical
- D. The next progress note and the problem list
Correct Answer: D 🗳️
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A patient's progress note states "The patient has chronic systolic heart failure". After reviewing clinical indicators suggestive of an exacerbation of systolic heart failure, the clinical documentation integrity practitioner (CDIP) queries the physician to clarify the current acuity of the diagnosis. Which subsequent documentation in the health record suggests the provider did not understand the query?
- A. The patient has acute on chronic systolic heart failure.
- B. The patient has chronic systolic heart failure.
- C. The patient did have an exacerbation of heart failure.
- D. The patient has decompensated systolic heart failure.
Correct Answer: B 🗳️
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