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AHIMA CDIP Exam Syllabus Topics:
| Section | Weight | Objectives |
|---|---|---|
| Topic 1: Research & Education | 11–15% | - Regulatory and guideline updates - Best practice research and implementation - Provider and staff education - Documentation improvement training materials |
| Topic 2: Record Review & Document Clarification | 24–28% | - Query tracking and follow-up - Identify documentation gaps and specificity issues - Ethical provider query development - Compliance with query standards - POA, HAC, SOI, ROM clarification |
| Topic 3: Clinical Coding Practice | 22–26% | - Payer requirements and reimbursement models - DRG, CPT, and HCPCS code assignment - ICD-10-CM/PCS coding conventions and guidelines - Coding software and reference resources - Principal and secondary diagnosis identification |
| Topic 4: Leadership | 17–22% | - CDI program development and promotion - Interdisciplinary collaboration - Policy and procedure creation - Provider engagement and communication |
| Topic 5: CDI Metrics & Statistics | 14–18% | - Query response and volume tracking - Benchmarking and reporting - DRG comparison and denial analysis - Quality audits and compliance monitoring |
| Topic 6: Compliance | 4–8% | - Fraud and abuse prevention - Legal and ethical documentation practices - AHIMA standards and regulatory requirements - Compliance monitoring and reporting |
AHIMA Certified Documentation Integrity Practitioner Sample Questions:
1. A patient receives a blood transfusion after a 400 ml blood loss during surgery. The clinical documentation integrity practitioner (CDIP) queries the physician for an associated diagnosis. The facility does not maintain queries as part of the permanent health record. What does the physician need to document for the CDIP to record the query as answered and agreed?
A) The associated diagnosis directly on the query form
B) That the blood loss was not clinically significant
C) A cause-and-effect relationship between anemia and the underlying cause
D) The associated diagnosis and the clinical rationale in the progress notes
2. A hospital noticed a 30% denial rate in Medicare claims due to lack of clinical documentation, placing the hospital at risk of multiple Medicare violations. What step should the clinical documentation integrity (CDI) manager take to help avoid future Medicare violations?
Collaborate with physician advisor/champion and revenue cycle manager
Instruct the billing department to write off claims with insufficient documentation
A) Assign pre-billing claim review duties to physicians
B) Prevent submission of claims for improper documentation
3. Which of the following is MOST likely to trigger a second-level review?
A) A diagnosis that impacts a quality-of-care measure
B) An account coded before the discharge summary is available
C) A record with multiple major complicating conditions (MCCs)
D) A procedure code that increases reimbursement
4. What type of query may NOT be used in circumstances where only clinical indicators of a condition are present, and the condition/diagnosis has not been documented in the health record?
A) Yes/No
B) Verbal
C) Multiple-choice
D) Open-ended
5. The facility has received a clinical validation denial for sepsis. The denial states sepsis is not a clinically valid diagnosis because it does not meet Sepsis-3 criteria. The facility has a policy stating it uses Sepsis-2 criteria.
What is the BEST next step?
A) Appeal the denial because all payors must use the hospital's sepsis criteria when reviewing their claims.
B) Remove sepsis from all claims where the diagnosis is not supported by sepsis 3 criteria.
C) Have the contracting department work with payors to obtain agreement on how sepsis will be clinically validated.
D) Query physicians when Sepsis-3 criteria is not met so they can provide additional documentation to support the diagnosis.
Solutions:
| Question # 1 Answer: D | Question # 2 Answer: A | Question # 3 Answer: C | Question # 4 Answer: A | Question # 5 Answer: C |




