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AHIMA CDIP Exam Syllabus Topics:
| Section | Weight | Objectives |
|---|---|---|
| Research & Education | 11–15% | - Provider and staff education - Best practice research and implementation - Documentation improvement training materials - Regulatory and guideline updates |
| Leadership | 17–22% | - Interdisciplinary collaboration - Provider engagement and communication - Policy and procedure creation - CDI program development and promotion |
| Compliance | 4–8% | - Fraud and abuse prevention - Legal and ethical documentation practices - Compliance monitoring and reporting - AHIMA standards and regulatory requirements |
| Record Review & Document Clarification | 24–28% | - Compliance with query standards - Ethical provider query development - Identify documentation gaps and specificity issues - POA, HAC, SOI, ROM clarification - Query tracking and follow-up |
| CDI Metrics & Statistics | 14–18% | - Quality audits and compliance monitoring - Query response and volume tracking - DRG comparison and denial analysis - Benchmarking and reporting |
| Clinical Coding Practice | 22–26% | - Coding software and reference resources - Payer requirements and reimbursement models - Principal and secondary diagnosis identification - ICD-10-CM/PCS coding conventions and guidelines - DRG, CPT, and HCPCS code assignment |
AHIMA Certified Documentation Integrity Practitioner Sample Questions:
1. When there are comparative contrasting diagnoses supported by clinical criteria, the correct action is to
A) query for clarification
B) code the first condition listed
C) not code either diagnosis
D) code both diagnoses
2. Educating physicians on severity of illness and risk of mortality is best accomplished by utilizing
A) the DRG Expert
B) physician report cards
C) the case mix index
D) case studies
3. Which of the following diagnosis is MOST likely to trigger a second level review?
A) Heart failure
B) Malnutrition
C) Acute kidney injury
D) Pneumonia
4. A hospital is conducting a documentation integrity project for the purpose of reducing indiscriminate use of electronic copy and paste of patient information in records by physicians. Which data should be used to quantify the extent of the problem?
A) Incidence of redundancies in physician notes in a sample of hospital admissions
B) Percent of insurance billings denied due to lack of record documentation
C) Number of coder queries regarding inconsistent physician record documentation
D) Results of a survey of physicians that asks about documentation practices
5. A 50-year-old with a history of stage II lung cancer is brought to the emergency department with severe dyspnea. The patient underwent the last round of chemotherapy
3 days ago. Vital signs reveal a temperature of 98.4, a heart rate of 98, a respiratory rate of 28, and a blood pressure of 124/82. O2 saturation on room air is 92%. The patient is 5'5"and weighs 98 lbs. The registered dietitian notes the patient is malnourished with BMI of 19.
Chest x-ray reveals a large pleural effusion in the right lung.
Thoracentesis is performed and 1000 cc serosanguinous fluid is removed. The admitting diagnosis is large right lung pleural effusion related to lung cancer stage II, documented multiple times. What post discharge query opportunity should be sent to the physician that will affect severity of illness (SOI)/risk of mortality (ROM)?
A) Query if the malignant pleural effusion is the reason for admission
B) Query for malignant pleural effusion
C) Query for a diagnosis associated with the dietician's finding of malnutrition
D) Query for protein calorie malnutrition
Solutions:
| Question # 1 Answer: D | Question # 2 Answer: D | Question # 3 Answer: B | Question # 4 Answer: A | Question # 5 Answer: B |
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