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Organizations working in the healthcare field place a significant value on clinical documentation integrity (CDI) competencies. This is particularly the case for professionals working in health information, nursing, and physician roles. These competencies are crucial for maintaining high standards of patient care and ensuring accurate record keeping. When an individual earns the Clinical Documentation Improvement Practitioner (CDIP) credential, they are demonstrating a high level of expertise in clinical documentation within patient health records. This expertise is essential in ensuring that patient healthcare information is properly recorded, stored, and managed.

The CDIP credential is not just a certification; it is a testament to the individual's dedication and proficiency in their field. Employers and colleagues alike look at CDIP holders as role models within the broader health information community. They are seen as leaders who uphold the highest standards in clinical documentation, setting an example for others to follow.

The process of earning the CDIP credential is rigorous and requires potential candidates to meet specific eligibility requirements. Candidates looking to sit for the CDIP examination must meet one of the following eligibility requirements:

- Hold an associate's degree or higher. This degree can be in any field but must be from a recognized and accredited institution. or

- Hold a Certified Coding Specialist (CCS), Certified Coding Specialist-Physician-based (CCS-P), Registered Health Information Technician (RHIT), or Registered Health Information Administrator (RHIA) credential. These are recognized credentials in the health information management field and demonstrate a candidate's prior knowledge and expertise.

Exam Name: Certified Documentation Integrity Practitioner

Number of Questions: 140

Duration: 3 hours

Format: computer-based format

Passing Score: 300

Member price: $259? 

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

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

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

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

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

1. The clinical documentation integrity (CDI) manager has noted a query response rate of 60%. The CDI practitioner reports that physicians often respond verbally to the query.

What can be done to improve this rate?

A. Have CDI manager teaming with coding supervisor to monitor physician responses

B. Require physicians to document responses in charts

C. Permit CDI practitioners to document physician responses in the charts

D. Allow physician to respond via e-mail

Answer: B

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. The ultimate purpose of clinical documentation integrity (CDI) expansion and growth is to __________.

A. provide community education to healthcare consumers

B. create synergy between clinical education and CDI principles

C. show a direct relationship between clinical documentation and quality patient care

D. promote CDI functions so that physicians view the CDI staff as value-added service

Answer: C

4. When there is a discrepancy between the clinical documentation integrity practitioner's (CDIP's) working DRG and the coder's final DRG, which of the following is considered a fundamental element that must be in place for a successful resolution?

A. Physician and CDIP interaction

B. Coder and CDIP interaction

C. Executive oversight

D. Physician advisor/champion involvement

Answer: B

5. Which of the following may make physicians lose respect for clinical documentation integrity (CDI) efforts and disengage?

A. Inconsistent clinically relevant queries

B. CDI practitioners sending multiple queries to hospitalist physicians

C. The physician advisor/champion's interventions with noncompliant physicians

D. Providing many lectures, newsletters, tip sheets, and pocket cards for physician education

Answer: A

6. A clinical documentation integrity practitioner (CDIP) is developing a plan to promote the CDI program throughout a major hospital. It is proving challenging to find support.

What is a primary step for the CDIP?

A. Determine primary interests and needs as requested

B. Determine primary interests of an individual or department

C. Teach coding classes to the new physicians as needed

D. Teach nursing staff about documentation integrity

Answer: B

7. An organization dealing with staffing shortages has adopted a policy requiring clinical documentation integrity practitioner (CDIP) to stop reviewing any record after a major complication or co-morbidity is found.

What is the unintended consequence of this?

A. Increase in case mix index

B. Reduced risk of clinical denials

C. Increased number of records reviewed by each CDIP

D. Decrease in severity of illness and risk of mortality

Answer: D

8. Which factors are important to include when refocusing the primary vision of a clinical documentation integrity (CDI) program?

A. Reporting and the use of technology

B. Value and mission statements

C. Benchmarks and case mix index

D. Diagnostic related groups and revenue cycle

Answer: B

9. The provider was queried because the patient met clinical criteria for acute hypoxic respiratory failure. The response to the query was different than what was expected by the clinical documentation integrity practitioner (CDIP).

What should the CDIP do?

A. Record the query response as disagreed

B. Have a different CDIP query the provider

C. Revise the query and send it back to the provider

D. Implement the department's escalation process

Answer: D

10. A pressure ulcer stage III is documented in the progress note. The clinical documentation integrity practitioner (CDIP) has queried the attending regarding the present on admission status of the pressure ulcer but has not received a response in an appropriate time frame.

What should the CDIP do next?

A. Escalate issue to medical staff leadership

B. Query wound care nurse

C. Escalate issue to hospital administration

D. Query surgical consultant

Answer: A