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AHIMA CDIP Exam Syllabus Topics:

SectionWeightObjectives
Record Review & Document Clarification- Review Clinical Records
  • 1. Identify documentation gaps and improvement areas
  • 2. Clarify clinical documentation with providers
Compliance- Regulatory and Compliance Fundamentals
  • 1. Understand documentation requirements and compliance
  • 2. Apply official guidelines (e.g., ICD-10-CM/PCS)
CDI Metrics & Statistics- Measure and Analyze CDI Performance
  • 1. Apply key CDI metrics
  • 2. Interpret documentation integrity data
Education and Leadership Development21–26%- Promote Documentation Integrity
  • 1. Develop and nurture collaborative relationships
  • 2. Promote CDI initiatives organization-wide
  • 3. Support multidisciplinary team documentation efforts
Clinical Coding Practice15–18%- Coding Application and Resources
  • 1. Assign and sequence diagnosis and procedure codes
  • 2. Use reference resources for code assignment
  • 3. Understand DRG and coding conventions

AHIMA Certified Documentation Integrity Practitioner Sample Questions:

For inpatients with a discharge principal diagnosis of acute myocardial infarction, aspirin must be taken within
24 hours of arrival unless a contraindication to aspirin is
documented. How should this be documented in the health record?

  • A. The name of the medication (aspirin) and the date it was last administered
  • B. The name of the medication (aspirin), the date and time it was last administered
  • C. The name of the medication (aspirin), the date, time and location where it was last administered
  • D. The name of the medication (aspirin), the date and location where it was last administered
Reveal Solution  Discussion  0

Correct Answer: C  🗳️

Explanation: Only visible for PremiumVCEDump members. You can sign-up / login (it's free).

After one year, the clinical documentation integrity (CDI) program has become stagnant, and the manager plans to reinvigorate the program to better reflect the CDI efforts in the organization. What can the manager do to ensure program success?

  • A. Prioritize to focus on efforts with the largest return on investment
  • B. Identify key metrics to develop program measures for coders
  • C. Establish a CDI steering committee to build a strong foundation
  • D. Expand the CDI program to larger areas in outpatient clinics
Reveal Solution  Discussion  0

Correct Answer: C  🗳️

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A 94-year-old female patient is admitted with altered mental status and inability to move the left side of her body. She is diagnosed with a cerebral vascular accident with left sided weakness. The patient is ambidextrous, but the physician does not specify the predominance of the affected side. The default code is

  • A. dominant
  • B. non-dominant
  • C. preferred
  • D. ambidextrous
Reveal Solution  Discussion  0

Correct Answer: B  🗳️

Explanation: Only visible for PremiumVCEDump members. You can sign-up / login (it's free).

Which of the following is a clinical documentation element supporting a transbronchial biopsy?

  • A. Hemoptysis
  • B. Pathology report documenting alveolar tissue
  • C. Pathology report documenting bronchial tissue
  • D. Length of procedure
Reveal Solution  Discussion  0

Correct Answer: B  🗳️

Explanation: Only visible for PremiumVCEDump members. You can sign-up / login (it's free).

A patient falls off a ladder and undergoes a right femur procedure. Three weeks later, the patient returns to the hospital for removal of the external fixation device. The ICD-10-CM 7th character code value should indicate

  • A. subsequent
  • B. aftercare
  • C. initial
  • D. sequela
Reveal Solution  Discussion  0

Correct Answer: B  🗳️

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