The Certified Documentation Integrity Practitioner (CDIP) Exam is widely regarded as one of the most prestigious certifications for Physician Advisors. This certification plays a crucial role in equipping professionals with the necessary skills and knowledge to excel in teaching CDI practices. PassQuestion offers a comprehensive range of up-to-date Certified Documentation Integrity Practitioner (CDIP) Exam Questions which are designed to help you prepare for your exam in a thorough and efficient manner. By utilizing these Certified Documentation Integrity Practitioner (CDIP) Exam Questions, you can significantly enhance your chances of success on your first attempt.

Certified Documentation Integrity Practitioner (CDIP)

A CDIP certificate, or Certified Document Improvement Practitioner certificate, is a designation that shows you have met all the qualifications set by the Commission on Certification for Health Informatics and Information Management (CCHIIM) and passed the CDIP exam. This certification confirms your mastery of skills in healthcare record management. Those who earn the credential have medical billing experience, understand medical codes and policies, possess other credentials in the field, and desire to advance their health care careers. Employers often view the credential as a sign of capability and commitment to a high standard of care. All medical professionals, from nurses and doctors to medical billers and coders, can apply for CDIP certification.

Eligibility Requirements

Candidates must meet one of the following eligibility requirements to sit for the CDIP® examination: 

• Hold an associate’s degree or higher; or
• Hold a CCS®, CCS-P®, RHIT®, or RHIA® credential

While not required, the following are recommended: 

• Minimum of two (2) years of clinical documentation integrity experience 
• Associate’s degree or higher in a health care or allied health care discipline 
• Completion of coursework in the following topics: 
• Medical terminology 
• Human anatomy and physiology 
• Pathology 
• Pharmacology

About the CDIP Exam

The CDIP is a timed exam. Candidates have three hours to complete the exam. The total number of questions on the exam is 140. There are 106 scored items and 34 pretest items. The exam is given in a computer-based format. AHIMA exams contain a variety of questions or item types that require you to use your knowledge, skills, and/or experience to select the best answer. Each exam includes scored questions and pretest questions randomly distributed throughout the exam. Pretest questions are for data collection purpose and they do not count towards candidate's score. The passing score for the CDIP is 300. 

Exam Content

Domain 1 – Clinical Coding Practice (15-18%)

1. Use reference resources for code assignment
2. Identify the principal and secondary diagnoses in order to accurately reflect the patient’s hospital course
3. Assign and sequence diagnosis and procedure codes
4. Apply coding conventions and guidelines related to diagnosis and procedure codes
5. Understand the assignment of the working and final DRG
6. 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

Domain 2 – Education and Leadership Development (21-26%)

1. Promote CDI efforts throughout the organization and health system, including administration
2. Create and nurture working relationships to support collaboration across multi-disciplinary teams
3. Develop documentation improvement projects
4. Collaborate with physician champions to promote CDI initiatives
5. Develop CDI policies and procedures in accordance with AHIMA practice briefs
6. Determine facility requirements for documentation of query responses in the record to establish official policy and procedures related to CDI query activities
7. Recognize a chain of command for resolving unanswered queries
8. Facilitate clinical documentation integrity by identifying educational topics and delivery methods for effective learning for an audience
9. Articulate the implications of accurate documentation and coding with respect to research, public health reporting, case management, and reimbursement

Domain 3 – Record Review & Document Clarification (27-33%)

1. Demonstrate comprehension of clinical documentation in health records
2. Identify and prioritize cases as part of the CDI review process
3. 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.)
4. Apply industry current best practices pertaining to query development and query processes
5. Identify strategies for obtaining query responses from providers and ensure provider query response is documented in the health record
6. Interact with providers to clarify documentation opportunities within the health record (e.g., patient quality indicators, Present on Admission (POA), acuteness/chronicity, complications, etc.)
7. Identify post-discharge query opportunities

Domain 4 – CDI Metrics & Statistics (8-11%)

1. Identify common dashboard metrics and monitor CDI departmental performance
2. Perform quality audits of CDI content to ensure compliance with institutional policies & procedures or national guidelines
3. Track metrics and interpret trends related to the physician query process (e.g., CDI perspective vs provider perspective)
4. Track and interpret data for physician benchmarking and trending
5. Compare institution with external institutional benchmarks
6. Identify common key performance metrics for CDI professionals
7. Use CDI data to adjust departmental workflow

Domain 5 – Compliance (18-23%)

1. Apply AHIMA and other industry standards in support of ethical CDI best practices
2. Monitor changes in the regulatory environment applicable to CDI activities to maintain compliance with all applicable agencies
3. Identify risks associated with technology (e.g., electronic health records, natural language processing (NLP), computer-assisted coding, etc.)
4. Identify situations when second level reviews are appropriate
5. Understand and appropriately use clinical validation queries
6. Identify and address non-compliant queries as part of a CDI workflow
7. Apply policies regarding various stages of the query process and time frames, including retention of queries, to avoid compliance risk

View Online Certified Documentation Integrity Practitioner (CDIP) Free Questions

1. A clinical documentation integrity practitioner (CDIP) generates a concurrent query and continues to follow retrospectively; however, the coder releases the bill before the query is answered. The CDIP wonders if it is appropriate to re-bill the account if the physician answers the query after the bill has dropped. Which policy should the hospital follow to avoid a compliance risk?
A.A rebilling is permissible when queries are answered after the initial bill.
B.A post-bill query rarely occurs as a result of an audit or other internal monitor.
C.A second bill should not be submitted when the first bill was incomplete.
D.A post bill query is not appropriate when an error is found after an audit.
Answer: A

2. A clinical documentation integrity practitioner (CDIP) hired by an internal medicine clinic is creating policies governing written queries. What is an AHIMA best practice for these policies?
A.Queries are limited to non-leading questions
B.Non-responses to written queries are grounds for discipline
C.Primary care physicians must answer written queries
D.Queries for illegible chart notes are unnecessary
Answer: A

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

4. The clinical documentation integrity (CDI) team in a hospital is initiating a project to change the unacceptable documentation behaviors of some physicians. What strategy should be part of a project aimed at improving these behaviors?
A.Expand use of coding queries by CDI team
B.Add a physician advisor/champion to the CDI team
C.Encourage physician-nurse cooperation
D.Alter the physician documentation requirements
Answer: B

5. A hospital administrator wants to initiate a clinical documentation integrity (CDI) program and has developed a steering committee to identify performance metrics. The CDI manager expects to use a case mix index as one of the metrics. Which other metric will need to be measured?
A.Comparison of risk of mortality with diagnostic related group capture rates
B.Assessment of APR-DRGs with capture of CC or MCC
C.Comparison of severity of illness with the CC capture rates
D.Assessment of CC/MCC capture rates
Answer: D

6. The clinical documentation integrity (CDI) manager is meeting with a steering committee to discuss the adoption of a new CDI program. The plan is to use case mix index (CMI) as a metric of CDI performance. How will this metric be measured?
A.Over time with a focus on high relative weight (RW) procedures that impact these procedures on overall CMI
B.Over time with a focus on particular documentation improvement areas in addition to the overall CMI
C.Month-to-month and focus on patient volumes to determine the raise the overall CMI
D.Month-to-month to show CMI variability as a barometer of a specific month
Answer: B

7. A hospital clinical documentation integrity (CDI) director suspects physicians are over-using electronic copy and paste in patient records, a practice that increases the risk of fraudulent insurance billings. A documentation integrity project may be needed. What is the first step the CDI director should take?
A.Recommend the physicians to be involved in the project
B.Bring together a team of physicians and informatics specialists
C.Alert senior leadership to the record documentation problem
D.Gather data on the incidence of inaccurate record documentation
Answer: D

8. 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.Look for wound care documentation
B.Read the nursing admission notes
C.Query the attending provider
D.Review the history and physical
Answer: D