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AHIMA CDIP Exam Syllabus Topics:
| Section | Weight | Objectives |
|---|---|---|
| Topic 1: CDI Metrics & Statistics | 14–18% | - Benchmarking and reporting - Query response and volume tracking - DRG comparison and denial analysis - Quality audits and compliance monitoring |
| Topic 2: Clinical Coding Practice | 22–26% | - Coding software and reference resources - DRG, CPT, and HCPCS code assignment - Principal and secondary diagnosis identification - Payer requirements and reimbursement models - ICD-10-CM/PCS coding conventions and guidelines |
| Topic 3: Research & Education | 11–15% | - Documentation improvement training materials - Regulatory and guideline updates - Best practice research and implementation - Provider and staff education |
| Topic 4: Leadership | 17–22% | - CDI program development and promotion - Interdisciplinary collaboration - Provider engagement and communication - Policy and procedure creation |
| Topic 5: Compliance | 4–8% | - AHIMA standards and regulatory requirements - Legal and ethical documentation practices - Fraud and abuse prevention - Compliance monitoring and reporting |
| Topic 6: Record Review & Document Clarification | 24–28% | - Compliance with query standards - Ethical provider query development - Query tracking and follow-up - Identify documentation gaps and specificity issues - POA, HAC, SOI, ROM clarification |
AHIMA Certified Documentation Integrity Practitioner Sample Questions:
A key physician approaches the director of the coding department about the new emphasis associated with clinical documentation integrity (CDI). The physician does not support the program and believes the initiative will encourage inappropriate billing.
How should the director respond to the concerns?
- A. Refer the physician to the finance department to discuss required billing changes
- B. Involve the physician advisor/champion in addressing the medical staff's concerns
- C. Inform the physician that changes must be made
- D. Develop an administrative panel to oversee CDI process
Correct Answer: B 🗳️
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Which of the following should be shared to ensure a clear sense of what clinical documentation integrity (CDI) is and the CDI practitioner's role within the organization?
- A. Review schedule
- B. Productivity standards
- C. Milestones
- D. Mission
Correct Answer: D 🗳️
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Which of the following individuals should the clinical documentation integrity (CDI) manager consult when developing query policy and procedures?
- A. Chief Financial Officer
- B. Chief Medical Officer
- C. CDI practitioner
- D. Compliance Officer
Correct Answer: B 🗳️
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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. Teach nursing staff about documentation integrity
- D. Determine primary interests and needs as requested
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 if the malignant pleural effusion is the reason for admission
- B. Query for protein calorie malnutrition
- 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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