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AHIMA CDIP Exam Syllabus Topics:
| Section | Weight | Objectives |
|---|---|---|
| Education and Leadership Development | 21ā26% | - CDI program leadership and organizational collaboration - Provider education and interdisciplinary communication - CDI project development and physician engagement |
| Record Review and Document Clarification | 24ā28% | - Post-discharge review and documentation validation - Provider query development and compliance - Clinical documentation review and gap identification |
| CDI Metrics and Statistics | - Performance metrics and reporting - Quality and outcome measurement (SOI/ROM) | |
| Compliance | - Audit readiness and documentation integrity standards - Regulatory compliance and ethical documentation practices | |
| Clinical Coding Practice | 15ā18% | - Coding fundamentals and guidelines application - Diagnosis and procedure code assignment and sequencing - DRG assignment and reimbursement concepts |
AHIMA Certified Documentation Integrity Practitioner Sample Questions:
The clinical documentation integrity (CDI) metrics recently showed a drastic drop in the physician query rate.
What might this indicate to the CDI manager?
- A. The program is successful because documentation has improved
- B. The decrease in hospital census has caused a lack of query opportunities
- C. CDI staff need education on identifying query opportunities
- D. The loss of a large volume of patients has impacted workflow
Correct Answer: C š³ļø
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Which of the following is a clinical documentation integrity (CDI) financial impact measure?
- A. Case mix index
- B. Hierarchical condition category
- C. Severity of illness
- D. Release of information
Correct Answer: A š³ļø
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An 88-year-old male is admitted with a fever, cough, and leukocytosis. The physician documents admit for probable sepsis due to urinary tract infection (UTI). Antibiotics are started. Three days later, the blood and urine cultures are negative, the patient has been afebrile since admission, and the white blood count is returning to normal. What documentation clarification is needed to support accurate coding of the record?
- A. Send a clinical validation query for both the diagnoses of sepsis and UTI.
- B. A clinical validation query is not required for either diagnosis.
- C. Send a clinical validation query for only the diagnosis of sepsis.
- D. Send a clinical validation query for only the diagnosis of UTI.
Correct Answer: A š³ļø
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A 27-year-old male patient presents to the emergency room with crampy, right lower quadrant abdominal pain, a low-grade fever (101Ā° Fahrenheit) and vomiting. The patient also has a history of type I diabetes mellitus. A complete blood count reveals mild leukocytosis (13,000/microliter). Abdominal ultrasound is ordered, and the patient is admitted for laparoscopic surgery. The patient is given an injection of neutral protamine Hagedorn insulin, in order to normalize the blood sugar level prior to surgery. Upon discharge, the attending physician documents "right lower quadrant abdominal pain due to possible acute appendicitis or probable Meckel diverticulitis".
What is the proper sequencing of the principal and secondary diagnoses?
- A. Right lower quadrant abdominal pain, acute appendicitis, Meckel diverticulitis, fever, vomiting, leukocytosis
- B. Right lower quadrant abdominal pain, fever, vomiting, leukocytosis
- C. Acute appendicitis, Meckel diverticulitis, type I diabetes mellitus
- D. Acute appendicitis, right lower quadrant abdominal pain, type I diabetes mellitus
Correct Answer: D š³ļø
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A clinical documentation integrity practitioner (CDIP) hired by an internal medicine clinic is creating policies governing written queries. What is an AHIMA best practice for these policies?
- A. Non-responses to written queries are grounds for discipline
- B. Queries are limited to non-leading questions
- C. Primary care physicians must answer written queries
- D. Queries for illegible chart notes are unnecessary
Correct Answer: B š³ļø
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