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AHIMA-CDIP exam Format | AHIMA-CDIP Course Contents | AHIMA-CDIP Course Outline | AHIMA-CDIP exam Syllabus | AHIMA-CDIP exam Objectives

Exam Code: CDIP

Exam Name: Certified Documentation Integrity Practitioner

Number of Questions: 100 multiple-choice questions

Time Allotted: 2 hours (120 minutes)

Passing Score: 300 (on a scale of 100–400)

Exam Format: Computer-based (CBT) at Pearson VUE testing centers or online proctored



- Clinical Coding Practice

- Use reference resources for code assignment

- Identify the principal and secondary diagnoses in order to accurately reflect the patients hospital course

- Assign and sequence diagnosis and procedure codes

- Apply coding conventions and guidelines related to diagnosis and procedure codes

- Understand the assignment of the working and final DRG

- Communicate with the coding/HIM staff to resolve discrepancies between the working and final DRGs, and to ensure coding and reimbursement updates are incorporated into practice



- Education and Leadership Development

- Promote CDI efforts throughout the organization and health system, including administration

- Create and nurture working relationships to support collaboration across multi-disciplinary teams

- Develop documentation improvement projects

- Collaborate with physician champions to promote CDI initiatives

- Develop CDI policies and procedures in accordance with AHIMA practice briefs

- Determine facility requirements for documentation of query responses in the record to establish official policy and procedures related to CDI query activities

- Recognize a chain of command for resolving unanswered queries

- Facilitate clinical documentation integrity by identifying educational courses and delivery methods for effective learning for an audience

- Articulate the implications of accurate documentation and coding with respect to research, public health reporting, case management, and reimbursement



- Record Review & Document Clarification

- Demonstrate comprehension of clinical documentation in health records

- Identify and prioritize cases as part of the CDI review process

- Identify gaps in documentation that may impact patient quality of care, code assignment, or reimbursement (e.g., command of disease process, clinical concepts, clinical validation opportunities, etc.)

- Apply industry current best practices pertaining to query development and query processes

- Identify strategies for obtaining query responses from providers and ensure provider query response is documented in the health record

- Interact with providers to clarify documentation opportunities within the health record (e.g., patient quality indicators, Present on Admission (POA), acuteness/chronicity, complications, etc.)

- Identify post-discharge query opportunities



- CDI Metrics & Statistics

- Identify common dashboard metrics and monitor CDI departmental performance

- Perform quality audits of CDI content to ensure compliance with institutional policies & procedures or national guidelines

- Track metrics and interpret trends related to the physician query process (e.g., CDI perspective vs provider perspective)

- Track and interpret data for physician benchmarking and trending

- Compare institution with external institutional benchmarks

- Identify common key performance metrics for CDI professionals

- Use CDI data to adjust departmental workflow



- Compliance

- Apply AHIMA and other industry standards in support of ethical CDI best practices

- Monitor changes in the regulatory environment applicable to CDI activities to maintain compliance with all applicable agencies

- Identify risks associated with technology (e.g., electronic health records, natural language processing (NLP), computer-assisted coding, etc.)

- Identify situations when second level reviews are appropriate

- Understand and appropriately use clinical validation queries

- Identify and address non-compliant queries as part of a CDI workflow

- Apply policies regarding various stages of the query process and time frames, including retention of queries, to avoid compliance risk

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