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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 - Principal and secondary diagnosis identification - DRG, CPT, and HCPCS code assignment - Coding software and reference resources - Payer requirements and reimbursement models |
| CDI Metrics & Statistics | 14–18% | - Quality audits and compliance monitoring - Query response and volume tracking - DRG comparison and denial analysis - Benchmarking and reporting |
| Leadership | 17–22% | - Interdisciplinary collaboration - Provider engagement and communication - CDI program development and promotion - Policy and procedure creation |
| 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 |
| Research & Education | 11–15% | - Best practice research and implementation - Documentation improvement training materials - Regulatory and guideline updates - Provider and staff education |
| Compliance | 4–8% | - Compliance monitoring and reporting - Fraud and abuse prevention - Legal and ethical documentation practices - AHIMA standards and regulatory requirements |
AHIMA Certified Documentation Integrity Practitioner Sample Questions:
1. An otherwise healthy male was admitted to undergo a total hip replacement as treatment for ongoing primary osteoarthritis of the right hip. During the post-operative period, the patient choked on liquids which resulted in aspiration pneumonia as shown on chest x-ray.
Intravenous antibiotics were administered, and the pneumonia was
monitored for improvement with two additional chest x-rays. The patient was discharged to home in stable condition on post-operative day 5.
Final Diagnoses:
1. Primary osteoarthritis of right hip status post uncomplicated total hip replacement
2. Aspiration pneumonia due to choking on liquid episode
What is the correct diagnostic related group assignment?
A) 553 Bone Diseases and Arthropathies with MCC
B) 179 Respiratory Infections and Inflammations without CC/MCC
C) 470 Major Joint Replacement or Reattachment of Lower Extremity without MCC
D) 469 Major Joint Replacement or Reattachment of Lower Extremity with MCC
2. The clinical documentation integrity (CDI) manager is reviewing physician benchmarks and notices a low-severity level being measured against average length of stay.
What should the CDI manager keep in mind when discussing this observation with physicians?
A) The diagnosis with a higher degree of specificity has a lower severity of illness.
B) The indicator is a key factor of measurement for quality reports.
C) The query rate is too high while the agreement rate is low.
D) The query response rate directly correlates to quality reports.
3. 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) Have the contracting department work with payors to obtain agreement on how sepsis will be clinically validated.
B) Query physicians when Sepsis-3 criteria is not met so they can provide additional documentation to support the diagnosis.
C) Appeal the denial because all payors must use the hospital's sepsis criteria when reviewing their claims.
D) Remove sepsis from all claims where the diagnosis is not supported by sepsis 3 criteria.
4. A patient was admitted for high fever and pain in umbilical region. During the second day of the hospital stay, the patient stood up to use the restroom and fell on the floor, resulting in a broken chin bone. A physician noted the fall on the second day in progress note. Which further clarification should be done regarding present on admission (POA) indicator of fall?
A) Query physician for POA
B) No query is needed
C) Bring this case up in weekly Health Information Management meetings for further action
D) Take the case to physician advisor/champion to discuss further action
5. Which of the following should an organization consider when developing a query retention policy and procedure?
A) Who should be queried
B) If the query is considered part of the health record
C) How the query will be formatted
D) What the escalation process will be
Solutions:
| Question # 1 Answer: D | Question # 2 Answer: B | Question # 3 Answer: A | Question # 4 Answer: A | Question # 5 Answer: B |




