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AHIMA CDIP Exam Syllabus Topics:
| Section | Weight | Objectives |
|---|---|---|
| Compliance | - Audit readiness and documentation integrity standards - Regulatory compliance and ethical documentation practices | |
| Education and Leadership Development | 21–26% | - CDI program leadership and organizational collaboration - Provider education and interdisciplinary communication - CDI project development and physician engagement |
| Record Review and Document Clarification | 24–28% | - Provider query development and compliance - Post-discharge review and documentation validation - Clinical documentation review and gap identification |
| Clinical Coding Practice | 15–18% | - Coding fundamentals and guidelines application - DRG assignment and reimbursement concepts - Diagnosis and procedure code assignment and sequencing |
| CDI Metrics and Statistics | - Quality and outcome measurement (SOI/ROM) - Performance metrics and reporting |
AHIMA Certified Documentation Integrity Practitioner Sample Questions:
A clinical documentation integrity practitioner (CDIP) is developing a plan to promote the CDI program throughout a major hospital. It is proving challenging to find support. What is a primary step for the CDIP?
- A. Teach coding classes to the new physicians as needed
- B. Determine primary interests of an individual or department
- C. Determine primary interests and needs as requested
- D. Teach nursing staff about documentation integrity
Correct Answer: B 🗳️
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Which of the following organizations should a clinical documentation integrity practitioner (CDIP) monitor?
- A. Office of Inspector General (OIG), Accreditation Commission for Healthcare (ACHC), Recovery Auditors (RAs)
- B. Recovery Auditors (RAs), Program for Evaluating Payment Patterns Electronic Report (PEPPER), Office of Inspector General (OIG)
- C. Program for Evaluating Payment Patterns Electronic Report (PEPPER), Recovery Auditors (RAs), Center for Improvement in Healthcare (CIHQ)
- D. Center for Improvement in Healthcare (CIHQ), Accreditation Commission for Healthcare (ACHC), Recovery Auditors (RAs)
Correct Answer: B 🗳️
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Identify the error in the following query:
This patient's echocardiogram showed an ejection fraction of 25%. The chest x-ray showed congestive heart failure (CHF). The patient was prescribed Lasix and an angiotensin-converting enzyme inhibitor (ACEI). Is this patient's CHF systolic?
- A. The query is unclear.
- B. The query contains irrelevant information.
- C. The query is leading.
- D. The query does not contain clinical indicators.
Correct Answer: C 🗳️
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A 94-year-old female patient is admitted with altered mental status and inability to move the left side of her body. She is diagnosed with a cerebral vascular accident with left sided weakness. The patient is ambidextrous, but the physician does not specify the predominance of the affected side. The default code is
- A. preferred
- B. ambidextrous
- C. dominant
- D. non-dominant
Correct Answer: D 🗳️
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A resident returns to the long-term care facility following hospital care for pneumonia. The physician's orders and progress note state "Continue IV antibiotics for pneumonia - 3 more days, after which time the resident is to have a repeat x-ray to determine status of the pneumonia". Is it appropriate to code the pneumonia in this scenario?
- A. Yes, J18.9, Pneumonia, unspecified organism, should be coded until the condition is resolved
- B. Yes J18.8, Pneumonia, other specified organism
- C. No, since the patient needed a repeat x-ray, the condition does not clarify as a diagnosis
- D. Yes, J18.9, Pneumonia, unspecified organism, Z79.2 should be coded along with long term antibiotics
Correct Answer: D 🗳️
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