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AHIMA CDIP Exam Syllabus Topics:
| Section | Weight | Objectives |
|---|---|---|
| Topic 1: Leadership | 17–22% | - Provider engagement and communication - CDI program development and promotion - Interdisciplinary collaboration - Policy and procedure creation |
| Topic 2: Record Review & Document Clarification | 24–28% | - POA, HAC, SOI, ROM clarification - Query tracking and follow-up - Identify documentation gaps and specificity issues - Ethical provider query development - Compliance with query standards |
| Topic 3: Clinical Coding Practice | 22–26% | - Payer requirements and reimbursement models - Principal and secondary diagnosis identification - Coding software and reference resources - ICD-10-CM/PCS coding conventions and guidelines - DRG, CPT, and HCPCS code assignment |
| Topic 4: Research & Education | 11–15% | - Regulatory and guideline updates - Documentation improvement training materials - Provider and staff education - Best practice research and implementation |
| Topic 5: CDI Metrics & Statistics | 14–18% | - DRG comparison and denial analysis - Query response and volume tracking - Benchmarking and reporting - Quality audits and compliance monitoring |
| Topic 6: Compliance | 4–8% | - Compliance monitoring and reporting - AHIMA standards and regulatory requirements - Legal and ethical documentation practices - Fraud and abuse prevention |
AHIMA Certified Documentation Integrity Practitioner Sample Questions:
Yes/No queries may be used
- A. when only the clinical indicators of a condition are present
- B. in any query format
- C. to resolve conflicting documentation from multiple practitioners
- D. when the diagnosis is not clearly documented in the health record
Correct Answer: C 🗳️
A patient presents to the emergency room with acute shortness of breath. The patient has a history of lung cancer that has been treated previously with radiation and chemotherapy. The patient is intubated and placed on mechanical ventilation. A chest x-ray is remarkable for a pleural effusion. A thoracentesis is performed, and the cytology results show malignant cells. Diagnoses on discharge: Acute respiratory failure due to recurrence of small cell carcinoma and malignant pleural effusion. Which coding reference takes precedence for assigning the ICD-10-CM/PCS codes?
- A. AHA Coding Clinic for ICD-10-CM/PCS
- B. Conventions and instructions of the classification for ICD-10-CM/PCS
- C. AMA CPT Assistant
- D. ICD-10-CM Official Guidelines for Coding and Reporting
Correct Answer: B 🗳️
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Hospital-acquired condition pay provisions apply only to
- A. critical access hospitals
- B. inpatient prospective payment system hospitals
- C. inpatient psychiatric hospitals
- D. long-term acute care hospitals
Correct Answer: B 🗳️
Explanation: Only visible for PassLeader members. You can sign-up / login (it's free).
A patient presented with shortness of breath, elevated B-type natriuretic peptide, and lower extremity edema to the emergency room. During the hospitalization, a cardiac echocardiogram was performed and revealed an ejection fraction of 55% with diastolic dysfunction. The patient's history includes hypertension (HTN), chronic kidney disease (CKD) (baseline glomerular filtration rate 40) and congestive heart failure (CHF). The clinical documentation integrity practitioner (CDIP) has queried the physician to further clarify the patient's diagnosis. Which response provides the highest level of specificity?
- A. Acute on chronic diastolic CHF with hypertensive renal disease, CKD 3
- B. Acute diastolic CHF with HTN and CKD 3
- C. Acute on chronic systolic CHF with hypertensive renal disease, CKD 3
- D. Acute CHF with hypertensive renal disease, CKD 3
Correct Answer: A 🗳️
Explanation: Only visible for PassLeader members. You can sign-up / login (it's free).
When there is a discrepancy between the clinical documentation integrity practitioner's (CDIP's) working DRG and the coder's final DRG, which of the following is considered a fundamental element that must be in place for a successful resolution?
- A. Coder and CDIP interaction
- B. Physician and CDIP interaction
- C. Executive oversight
- D. Physician advisor/champion involvement
Correct Answer: A 🗳️
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