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AHIMA CDIP Exam Syllabus Topics:
| Section | Weight | Objectives |
|---|---|---|
| Topic 1: Record Review & Document Clarification | - Review Clinical Records
| |
| Topic 2: Education and Leadership Development | 21–26% | - Promote Documentation Integrity
|
| Topic 3: Compliance | - Regulatory and Compliance Fundamentals
| |
| Topic 4: Clinical Coding Practice | 15–18% | - Coding Application and Resources
|
| Topic 5: CDI Metrics & Statistics | - Measure and Analyze CDI Performance
|
AHIMA Certified Documentation Integrity Practitioner Sample Questions:
When queries are part of the health record, which of the following physician privilege could be suspended if the provider receives too many deficiencies due to incomplete records for failure to respond to queries?
- A. Surgical
- B. Consulting
- C. Admitting
- D. Credentialing
Correct Answer: C 🗳️
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Which of the following may make physicians lose respect for clinical documentation integrity (CDI) efforts and disengage?
- A. Inconsistent clinically relevant queries
- B. Providing many lectures, newsletters, tip sheets, and pocket cards for physician education
- C. CDI practitioners sending multiple queries to hospitalist physicians
- D. The physician advisor/champion's interventions with noncompliant physicians
Correct Answer: A 🗳️
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A clinical documentation integrity practitioner (CDIP) must determine the present on admission (POA) status of a stage IV sacral decubitus ulcer documented in the discharge summary. What is the first step that should be taken?
- A. Query the attending provider
- B. Look for wound care documentation
- C. Review the history and physical
- D. Read the nursing admission notes
Correct Answer: C 🗳️
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An 80-year-old male is admitted as an inpatient to the ICU with shortness of breath, productive yellow sputum, and a temperature of 101.2. CXR reveals bilateral pleural effusion and LLL pneumonia. Labs reveal a BUN of 42 and a creatinine level of 1.500.
The patient is given Zithromax 500 mg. IV, NS IV, and Lasix 40 mg tabs 2x/day. The attending physician documents bilateral pleural effusion, LLL pneumonia, and kidney failure. Two days later, the renal consult documents AKI with acute tubular necrosis (ATN). The correct principal and secondary diagnoses are
- A. PDx: LLL pneumonia
SDx: Bilateral pleural effusion, kidney failure - B. PDx: Bilateral pleural effusion
SDx: LLL pneumonia, kidney failure - C. PDx: AKI with ATN
SDx: LLL pneumonia, bilateral pleural effusion - D. PDx: LLL pneumonia
SDx: AKI with ATN, bilateral pleural effusion
Correct Answer: D 🗳️
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Which of the following individuals should the clinical documentation integrity (CDI) manager consult when developing query policy and procedures?
- A. Compliance Officer
- B. Chief Medical Officer
- C. CDI practitioner
- D. Chief Financial Officer
Correct Answer: B 🗳️
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