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AHIMA CDIP Exam Syllabus Topics:
| Section | Weight | Objectives |
|---|---|---|
| Topic 1: Clinical Coding Practice | 22–26% | - DRG, CPT, and HCPCS code assignment - Principal and secondary diagnosis identification - Payer requirements and reimbursement models - Coding software and reference resources - ICD-10-CM/PCS coding conventions and guidelines |
| Topic 2: Record Review & Document Clarification | 24–28% | - Ethical provider query development - POA, HAC, SOI, ROM clarification - Compliance with query standards - Query tracking and follow-up - Identify documentation gaps and specificity issues |
| Topic 3: Leadership | 17–22% | - Policy and procedure creation - Interdisciplinary collaboration - Provider engagement and communication - CDI program development and promotion |
| Topic 4: CDI Metrics & Statistics | 14–18% | - DRG comparison and denial analysis - Query response and volume tracking - Quality audits and compliance monitoring - Benchmarking and reporting |
| Topic 5: Research & Education | 11–15% | - Documentation improvement training materials - Regulatory and guideline updates - Provider and staff education - Best practice research and implementation |
| Topic 6: Compliance | 4–8% | - Fraud and abuse prevention - Compliance monitoring and reporting - Legal and ethical documentation practices - AHIMA standards and regulatory requirements |
What Candidates Ask Before Preparing for CDIP with GuideTorrent
- Leadership (17–22%)
- Clinical Coding Practice (22–26%)
- Record Review & Document Clarification (24–28%)
AHIMA Certified Documentation Integrity Practitioner Sample Questions:
Which physician would best benefit from additional education for unanswered queries?
- A. Dr. C
- B. Dr. D
- C. Dr. A
- D. Dr. B
Correct Answer: B 🗳️
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The most beneficial step to identify post-discharge query opportunities that affect severity of illness, risk of mortality and case weight is to
- A. look for documented conditions that have well supported accompanying clinical criteria
- B. watch for reportable conditions or conditions that are unambiguous or otherwise complete
- C. identify normal diagnostic test results that may indicate a possible addition of a secondary diagnosis
- D. determine if only the treatment is documented and there is no diagnosis documented
Correct Answer: D 🗳️
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. dominant
- C. ambidextrous
- D. non-dominant
Correct Answer: D 🗳️
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A 56-year-old male patient complains of feeling fatigued, has nausea & vomiting, swelling in both legs.
Patient has history of chronic kidney disease (CKD) stage III,
coronary artery disease (CAD) & hypertension (HTN). He is on Lisinopril. Vital signs: BP 160/80, P 84, R 20, T 100.OF. Labs: WBC 11.5 with 76% segs, GFR 45. CXR showed slight left lower lobe haziness. Patient was admitted for acute kidney injury (AKI) with acute tubular necrosis (ATN). He was scheduled for hemodialysis the next day. Two days after admission patient started coughing, fever of 101.8F, CXR showed left lower lobe infiltrate, possible pneumonia. Attending physician documented that patient has pneumonia and ordered Rocephin IV. How should the clinical documentation integrity practitioner (CDIP) interact with the physician to clarify whether or not the pneumonia is a hospital-acquired condition (HAC)?
- A. Dr. Adair, please indicate if the patient's pneumonia was present on admission (POA) based on the initial chest x-ray?
- B. Dr. Adair, in your clinical opinion, do you think that the patient's acute kidney injury with ATN exacerbated the patient's pneumonia?
- C. No need to query the physician because even if the pneumonia is considered a HAC and cannot be used as an MCC, ATN is also an MCC.
- D. No need to interact with the physician because it is obvious the pneumonia developed after admission, therefore, not present on admission.
Correct Answer: A 🗳️
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A hospital clinical documentation integrity (CDI) director suspects physicians are over-using electronic copy and paste in patient records, a practice that increases the risk of fraudulent insurance billings. A documentation integrity project may be needed. What is the first step the CDI director should take?
- A. Alert senior leadership to the record documentation problem
- B. Bring together a team of physicians and informatics specialists
- C. Gather data on the incidence of inaccurate record documentation
- D. Recommend the physicians to be involved in the project
Correct Answer: C 🗳️
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