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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