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AHIMA CDIP Exam Syllabus Topics:
| Section | Weight | Objectives |
|---|---|---|
| Record Review and Document Clarification | 24–28% | - Post-discharge review and documentation validation - Clinical documentation review and gap identification - Provider query development and compliance |
| Clinical Coding Practice | 15–18% | - DRG assignment and reimbursement concepts - Diagnosis and procedure code assignment and sequencing - Coding fundamentals and guidelines application |
| CDI Metrics and Statistics | - Quality and outcome measurement (SOI/ROM) - Performance metrics and reporting | |
| Compliance | - Audit readiness and documentation integrity standards - Regulatory compliance and ethical documentation practices | |
| Education and Leadership Development | 21–26% | - Provider education and interdisciplinary communication - CDI program leadership and organizational collaboration - CDI project development and physician engagement |
AHIMA Certified Documentation Integrity Practitioner Sample Questions:
The correct coding for heart failure with preserved ejection fraction is
- A. I50.30 Unspecified diastolic (congestive) heart failure
- B. I50.9 Heart failure, unspecified
- C. I50.20 Unspecified systolic (congestive) heart failure
- D. 150.32 Chronic diastolic (congestive) heart failure
Correct Answer: A 🗳️
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The clinical documentation integrity (CDI) team in a hospital is initiating a project to change the unacceptable documentation behaviors of some physicians. What strategy should be part of a project aimed at improving these behaviors?
- A. Encourage physician-nurse cooperation
- B. Add a physician advisor/champion to the CDI team
- C. Alter the physician documentation requirements
- D. Expand use of coding queries by CDI team
Correct Answer: B 🗳️
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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 for protein calorie malnutrition
- B. Query if the malignant pleural effusion is the reason for admission
- C. Query for a diagnosis associated with the dietician's finding of malnutrition
- D. Query for malignant pleural effusion
Correct Answer: D 🗳️
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Proposed changes to the inpatient prospective payment system (IPPS) take effect on
- A. July 1
- B. October 1
- C. April 1
- D. January 1
Correct Answer: B 🗳️
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When a change in departmental workflow is necessary, the first step is to
- A. define the gaps and solutions
- B. re-engineer the process
- C. assess the current workflow
- D. set realistic timelines
Correct Answer: C 🗳️
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