AHIMA CDIP Certification Sample Questions

The AHIMA Certified Documentation Integrity Practitioner Certification Sample Question Set on this page is designed to familiarize you with the actual AHIMA CDIP exam format and question types. These sample questions help you understand how questions are structured and what to expect on test day. While they provide a useful starting point, they represent only a limited preview of the real exam experience.

These sample questions are intended for evaluation and familiarization only. To understand exam style, pacing, and reasoning patterns more clearly, we recommend trying our online sample practice environment. If you are preparing for the AHIMA Certified Documentation Integrity Practitioner (CDIP) and want to assess your readiness more rigorously, structured, timed, scenario-based practice is recommended. This approach aligns with the cognitive demands and professional expectations typically associated with Clinical documentation specialists, health information management professionals, coding and compliance professionals working in settings such as Hospitals and health systems, outpatient and physician practices, healthcare consulting and revenue cycle organizations.

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The demo introduces core concepts, while full-length premium simulations provide deeper, scenario-based coverage that more closely reflects the actual cognitive demands of the AHIMA Certified Documentation Integrity Practitioner exam, particularly in areas such as Clinical documentation integrity review, coding and reimbursement principles, regulatory compliance and quality reporting. You can use these sample questions as a starting point, then progress to the AHIMA CDIP Certification Practice Exam for stronger readiness. Our premium simulations are designed to mirror real exam conditions, helping you refine reasoning, pacing, and decision-making before your official exam attempt.

AHIMA CDIP Sample Questions:

01. A facility's policy routes accounts to second-level review when the MS-DRG depends on a single MCC. On one routed account the reviewer confirmed that the MCC, acute kidney injury, was well supported by a creatinine rise from 0.9 to 2.4 mg/dL and IV fluid treatment, and released the claim. A later external audit found that pneumonia had been sequenced as the principal diagnosis, although the attending documented that the patient was admitted for a hip fracture from a fall and that the pneumonia developed on day 3. What does this finding show about the second-level review process?
a) The trigger was set too narrowly and should also have routed every account with a pneumonia diagnosis
b) The external auditor erred, because an account cleared at second-level review is final for audit purposes
c) The review checked the trigger, not the whole coded account
d) The coder alone was responsible for sequencing, so the reviewer's sign-off on the account carries no accountability

02. A physician benchmarking report ranks hospitalists by CC/MCC capture rate, attributing each discharge to the physician who signs the discharge summary. Dr. Okafor ranks lowest in the group. A CDI look at her discharges finds that she covers most Monday discharges, and that for most of those patients a different hospitalist wrote the history and physical and every progress note through the weekend. How should the CDI manager treat Dr. Okafor's ranking?
a) Re-run the comparison with each result attributed to the physician who wrote the documentation in question
b) Use the ranking to schedule one-on-one education with Dr. Okafor, since the discharge summary governs coding
c) Compare her with hospitalists who also cover Monday discharges, keeping attribution by discharge summary
d) Remove Dr. Okafor from the report, as covering physicians cannot be fairly compared with others

03. A CDI specialist forwards a consulting firm's newsletter article stating that a new national coding instruction requires providers to use a specific linking phrase before an organism can be coded with pneumonia. The specialist proposes adding the phrase to every pneumonia query template this week. What should the CDI manager do FIRST?
a) Add the phrase to the templates as optional wording now, and remove it later if the change proves false
b) Check whether other hospitals in the health system have already adopted the phrase in their templates
c) Have the coding manager find the instruction in the Official Guidelines or Coding Clinic before anything changes
d) Survey the hospitalists on whether they would accept using the new phrase in their notes

04. A CDI professional reviews the query report by topic and finds that acute blood loss anemia accounts for a large share of all queries sent to the surgical department. What does this trend MOST likely indicate?
a) A reason to let coders assign the anemia from hemoglobin values
b) A coding error rate that should be reported to compliance as a potential billing problem
c) A need to add acute blood loss anemia to the postoperative order set as a default diagnosis
d) A recurring documentation gap that calls for targeted surgeon education

05. A hospital policy states: "Query responses must be signed and dated by the provider within 48 hours of discharge." What kind of requirement is this?
a) A facility requirement for documenting query responses
b) A federal requirement that applies to every hospital
c) An instruction from the ICD-10-CM Official Guidelines for Coding and Reporting
d) An AHIMA practice brief mandate binding on all facilities

06. The medical staff has approved the criteria the CDI team uses to screen for clinical validation queries. A hospitalist documents "toxic encephalopathy due to gabapentin accumulation in the setting of acute kidney injury." The record shows new confusion and myoclonus on admission, gabapentin held, and mental status back to baseline on day 3 as renal function improves. A head CT is normal. A newer CDI specialist proposes a clinical validation query because the head CT was normal. What is the BEST response?
a) Send the query to the neurology service instead of the hospitalist, letting neurology weigh the normal CT
b) No query is needed, as the documented indicators support the diagnosis
c) Have the coder hold the encephalopathy code until the hospitalist documents an imaging finding that supports it
d) Send the query, presenting the normal CT beside the mental status findings, with confirm, rule out, other and undetermined options

07. A physician documents "history of stroke" in the H&P. The patient currently has left-sided hemiparesis being treated by physical therapy, and the physician has not stated its cause. What should the CDI specialist do?
a) Accept "history of stroke" and report a personal-history code only
b) Query whether the hemiparesis is a stroke sequela
c) Report a current acute stroke with hemiparesis from the H&P
d) Ask the physical therapist to document the cause of the hemiparesis

08. A post-discharge query is needed to clarify whether a documented "acute kidney injury" was present on admission. The attending of record has started a six-week medical leave, and the account must be final-coded within the facility's 30-day window. Query policy permits redirecting a query to another provider who treated the patient during the stay. A second hospitalist admitted the patient, wrote the H&P and documented the admission creatinine and IV fluids on days 1 and 2. A nephrologist saw the patient once on day 4, when creatinine was improving, and did not comment on renal status at admission. To whom is the query MOST appropriately directed?
a) The hospitalist who admitted the patient and documented the early creatinine
b) The hospitalist group's medical director, who can answer for any provider in the group
c) The nephrologist, who saw the patient on day 4 and wrote the longest renal note
d) No one until the attending returns, because only the attending of record may answer a post-discharge query

09. An annual coding guideline change altered how a condition the CDI team often clarifies is reported. Coding applied the change on its effective date, but the CDI query templates and tip sheets carried the old instruction for four months afterward. Asked how the department tracks regulatory change, the CDI manager explains that specialists read whatever newsletters reach them, and the coding manager forwards the items she thinks are relevant to CDI. Which change BEST prevents a repeat?
a) Ask the coding manager to forward every guideline item she receives, not only the ones she judges relevant
b) Subscribe every specialist to several national CDI newsletters so that more of the team sees each change
c) Assign an owner to check named official sources on a schedule and log each change, its action and staff notice
d) Rely on the encoder vendor's annual update, which loads the new code set and guidelines into the coding software

10. While assigning codes, a coder finds the instructional note "Code first underlying condition" under the code for a documented manifestation. What does this note require?
a) Report the underlying condition only if listed as the principal diagnosis
b) Sequence the code carrying the note first, as it describes the reason for care
c) Query the provider about which condition to list first
d) Sequence the underlying condition first, followed by the code that carries the note

Answers:

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Note: These sample questions are not official exam questions and are intended only for familiarization and study purposes. If you find any typos or data entry errors in these AHIMA Certified Documentation Integrity Practitioner (CDIP) sample questions, please let us know by emailing us at feedback@medicoexam.com