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AHIMA CDIP Exam Syllabus Topics:
| Section | Weight | Objectives |
|---|---|---|
| Clinical Coding Practice | 22–26% | - ICD-10-CM/PCS coding conventions and guidelines - DRG, CPT, and HCPCS code assignment - Payer requirements and reimbursement models - Coding software and reference resources - Principal and secondary diagnosis identification |
| Compliance | 4–8% | - Fraud and abuse prevention - AHIMA standards and regulatory requirements - Compliance monitoring and reporting - Legal and ethical documentation practices |
| Research & Education | 11–15% | - Best practice research and implementation - Regulatory and guideline updates - Documentation improvement training materials - Provider and staff education |
| Record Review & Document Clarification | 24–28% | - Ethical provider query development - Query tracking and follow-up - Identify documentation gaps and specificity issues - Compliance with query standards - POA, HAC, SOI, ROM clarification |
| CDI Metrics & Statistics | 14–18% | - Query response and volume tracking - Benchmarking and reporting - DRG comparison and denial analysis - Quality audits and compliance monitoring |
| Leadership | 17–22% | - Policy and procedure creation - Interdisciplinary collaboration - Provider engagement and communication - CDI program development and promotion |
AHIMA Certified Documentation Integrity Practitioner Sample Questions:
1. When writing a compliant query, best practice is to
A) include all relevant clinical indicators
B) use a yes/no query format for specificity of a diagnosis
C) use the term "possible" to describe a condition or diagnosis when uncertain if the diagnosis is present
D) direct the physician to a specific diagnosis
2. The clinical documentation integrity practitioner (CDIP) is reviewing tracking data and has noted physician responses are not captured in the medical chart. What can be done to improve this process?
A) Provide education to physicians on query process
B) Require the CDIP to call physicians to follow up
C) Allow physician responses via e-mail
D) Update medical records with unsigned physician responses
3. A 75-year-old, diabetic patient with a history of osteoporosis, being treated with Fosamax, who sustained a femur fracture after falling down three stairs. The provider's documentation indicates to admit the patient for a traumatic femur fracture and an orthopedics consult is pending. The clinical documentation integrity practitioner (CDIP) decides to query for a possible link between osteoporosis and the femur fracture. Which of the following is the most compliant query based on the most recent AHIMA/ACDIS query practice brief?
A) Patient admitted for a femur fracture with a history of osteoporosis being treated with Fosamax. Please clarify the cause of the femur fracture in your next note and/or the discharge summary.
B) Patient admitted for a femur fracture with a history of osteoporosis being treated with Fosamax. In your medical opinion, is this fracture consistent with an osteoporotic pathological fracture?
C) Patient admitted for a femur fracture with a history of osteoporosis being treated with Fosamax. Please document "femur fracture due to osteoporosis" in your next progress note to demonstrate a link between the two diagnoses.
D) Patient admitted for a femur fracture with a history of osteoporosis being treated with Fosamax. Could diabetes be a contributing factor in the femur fracture?
4. 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) Queries are limited to non-leading questions
B) Queries for illegible chart notes are unnecessary
C) Non-responses to written queries are grounds for discipline
D) Primary care physicians must answer written queries
5. A physician documented the specific site of the malignancy in the medical record documentation; however, the coder is unable to locate a specific entry in the ICD-10- CM Alphabetical Index to match the specified diagnosis. Which abbreviation used in the Alphabetical Index will assist the coder in assigning the appropriate diagnosis code for the specified condition?
A) NOS
B) NEC
C) DRG
D) OCE
Solutions:
| Question # 1 Answer: A | Question # 2 Answer: A | Question # 3 Answer: B | Question # 4 Answer: A | Question # 5 Answer: B |
