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Updated: Aug 02, 2026
Q & A: 140 Questions and Answers
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| Section | Weight | Objectives |
|---|---|---|
| Topic 1: Compliance | 4–8% | - AHIMA standards and regulatory requirements - Legal and ethical documentation practices - Compliance monitoring and reporting - Fraud and abuse prevention |
| Topic 2: Record Review & Document Clarification | 24–28% | - Identify documentation gaps and specificity issues - Ethical provider query development - POA, HAC, SOI, ROM clarification - Compliance with query standards - Query tracking and follow-up |
| Topic 3: Research & Education | 11–15% | - Documentation improvement training materials - Regulatory and guideline updates - Best practice research and implementation - Provider and staff education |
| Topic 4: Clinical Coding Practice | 22–26% | - Payer requirements and reimbursement models - ICD-10-CM/PCS coding conventions and guidelines - Coding software and reference resources - Principal and secondary diagnosis identification - DRG, CPT, and HCPCS code assignment |
| Topic 5: Leadership | 17–22% | - Provider engagement and communication - Interdisciplinary collaboration - Policy and procedure creation - CDI program development and promotion |
| Topic 6: CDI Metrics & Statistics | 14–18% | - Quality audits and compliance monitoring - Benchmarking and reporting - Query response and volume tracking - DRG comparison and denial analysis |
1. The clinical documentation integrity practitioner (CDIP) is reviewing tracking data and has noted physician responses are not captured in the medical chart. What can be done to improve this process?
A) Update medical records with unsigned physician responses
B) Allow physician responses via e-mail
C) Provide education to physicians on query process
D) Require the CDIP to call physicians to follow up
2. 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) Have a different CDIP query the provider
B) Record the query response as disagreed
C) Implement the department's escalation process
D) Revise the query and send it back to the provider
3. What policies should query professionals follow?
A) AHIMA's policies related to querying
B) CMS's policies related to querying
C) All healthcare entity's policies are the same
D) Their healthcare entity's internal policies related to querying
4. Educating physicians on severity of illness and risk of mortality is best accomplished by utilizing
A) physician report cards
B) case studies
C) the case mix index
D) the DRG Expert
5. Hospital-acquired condition pay provisions apply only to
A) inpatient psychiatric hospitals
B) inpatient prospective payment system hospitals
C) long-term acute care hospitals
D) critical access hospitals
Solutions:
| Question # 1 Answer: C | Question # 2 Answer: C | Question # 3 Answer: D | Question # 4 Answer: B | Question # 5 Answer: B |
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