AHIMA CDIP Practice Exams
Last updated on Oct 21,2026- Exam Code: CDIP
- Exam Name: Certified Documentation Integrity Practitioner
- Certification Provider: AHIMA
- Latest update: Oct 21,2026
Question #1
Identify the error in the following query:
This patient’s echocardiogram showed an ejection fraction of 25%. The chest x-ray showed congestive heart failure (CHF). The patient was prescribed Lasix and an angiotensin-converting enzyme inhibitor (ACEI).
Is this patient’s CHF systolic?
- A . The query is unclear.
- B . The query contains irrelevant information.
- C . The query does not contain clinical indicators.
- D . The query is leading.
Correct Answer: D
D
Explanation:
A leading query is one that suggests a specific diagnosis, condition, or treatment to the provider, or implies that a certain response is desired or expected. A leading query can compromise the integrity and accuracy of the documentation and the coded data, and may also raise compliance and ethical issues. A query should be non-leading, meaning that it presents the facts from the health record without bias or influence, and allows the provider to use their clinical judgment to determine the appropriate response.
The query in the question is leading because it implies that the patient’s CHF is systolic by asking a yes/no question that only offers one option. A non-leading query would ask an open-ended question that offers multiple options, such as “What type of CHF does this patient have?” or “Please specify the type of CHF: systolic, diastolic, or combined.”
References:
CDIP Exam Preparation Guide, 2021 Edition. AHIMA Press. ISBN: 9781584268530
Guidelines for Achieving a Compliant Query Practice―2022 Update | ACDIS
Guidelines for Achieving a Compliant Query Practice (2019 Update) – AHIMA
The Provider Query Toolkit: A Guide to Compliant Practices
D
Explanation:
A leading query is one that suggests a specific diagnosis, condition, or treatment to the provider, or implies that a certain response is desired or expected. A leading query can compromise the integrity and accuracy of the documentation and the coded data, and may also raise compliance and ethical issues. A query should be non-leading, meaning that it presents the facts from the health record without bias or influence, and allows the provider to use their clinical judgment to determine the appropriate response.
The query in the question is leading because it implies that the patient’s CHF is systolic by asking a yes/no question that only offers one option. A non-leading query would ask an open-ended question that offers multiple options, such as “What type of CHF does this patient have?” or “Please specify the type of CHF: systolic, diastolic, or combined.”
References:
CDIP Exam Preparation Guide, 2021 Edition. AHIMA Press. ISBN: 9781584268530
Guidelines for Achieving a Compliant Query Practice―2022 Update | ACDIS
Guidelines for Achieving a Compliant Query Practice (2019 Update) – AHIMA
The Provider Query Toolkit: A Guide to Compliant Practices
Question #2
The clinical documentation integrity (CDI) manager is reviewing physician benchmarks and notices a low-severity level being measured against average length of stay.
What should the CDI manager keep in mind when discussing this observation with physicians?
- A . The indicator is a key factor of measurement for quality reports.
- B . The query rate is too high while the agreement rate is low.
- C . The query response rate directly correlates to quality reports.
- D . The diagnosis with a higher degree of specificity has a lower severity of illness.
Correct Answer: A
A
Explanation:
According to the AHIMA CDIP Exam Preparation Guide, one of the CDI metrics and statistics that CDI managers should track and interpret is the severity level measured against average length of stay (ALOS)1. This indicator reflects the complexity and acuity of the patient population and the quality of care provided by the hospital2. A low-severity level with a high ALOS may indicate under-documentation or under-coding of the patient’s condition, which may affect the hospital’s reimbursement, risk adjustment, and quality scores3. Therefore, the CDI manager should keep in mind that this indicator is a key factor of measurement for quality reports when discussing this observation with physicians, and educate them on the importance of documenting and coding accurately and completely to reflect the patient’s true severity of illness. The other options are not correct because they do not address the issue of severity level measured against ALOS, or they are not relevant to the CDI manager’s role or responsibility. References:
CDIP Exam Preparation Guide – AHIMA
Demystifying and communicating case-mix index – ACDIS
Severity of Illness: What Is It? Why Is It Important? | HCPro
A
Explanation:
According to the AHIMA CDIP Exam Preparation Guide, one of the CDI metrics and statistics that CDI managers should track and interpret is the severity level measured against average length of stay (ALOS)1. This indicator reflects the complexity and acuity of the patient population and the quality of care provided by the hospital2. A low-severity level with a high ALOS may indicate under-documentation or under-coding of the patient’s condition, which may affect the hospital’s reimbursement, risk adjustment, and quality scores3. Therefore, the CDI manager should keep in mind that this indicator is a key factor of measurement for quality reports when discussing this observation with physicians, and educate them on the importance of documenting and coding accurately and completely to reflect the patient’s true severity of illness. The other options are not correct because they do not address the issue of severity level measured against ALOS, or they are not relevant to the CDI manager’s role or responsibility. References:
CDIP Exam Preparation Guide – AHIMA
Demystifying and communicating case-mix index – ACDIS
Severity of Illness: What Is It? Why Is It Important? | HCPro
Question #3
What type of query may NOT be used in circumstances where only clinical indicators of a condition are present, and the condition/diagnosis has not been documented in the health record?
- A . Multiple-choice
- B . Open-ended
- C . Verbal
- D . Yes/No
Correct Answer: D
D
Explanation:
A yes/no query may not be used in circumstances where only clinical indicators of a condition are present, and the condition/diagnosis has not been documented in the health record because it may lead to leading or suggesting a diagnosis that is not supported by the provider’s documentation. A yes/no query should only be used when there is clear and consistent documentation of a condition/diagnosis in the health record, and the query is seeking confirmation or denial of a specific fact or detail related to that condition/diagnosis. A multiple-choice, open-ended, or verbal query may be more appropriate to allow the provider to choose from a list of possible diagnoses, provide additional information, or explain the clinical reasoning behind the documentation. (CDIP Exam Preparation Guide)
References:
CDIP Exam Content Outline1
CDIP Exam Preparation Guide2
AHIMA Practice Brief: Guidelines for Achieving a Compliant Query Practice3
D
Explanation:
A yes/no query may not be used in circumstances where only clinical indicators of a condition are present, and the condition/diagnosis has not been documented in the health record because it may lead to leading or suggesting a diagnosis that is not supported by the provider’s documentation. A yes/no query should only be used when there is clear and consistent documentation of a condition/diagnosis in the health record, and the query is seeking confirmation or denial of a specific fact or detail related to that condition/diagnosis. A multiple-choice, open-ended, or verbal query may be more appropriate to allow the provider to choose from a list of possible diagnoses, provide additional information, or explain the clinical reasoning behind the documentation. (CDIP Exam Preparation Guide)
References:
CDIP Exam Content Outline1
CDIP Exam Preparation Guide2
AHIMA Practice Brief: Guidelines for Achieving a Compliant Query Practice3
Question #4
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
Correct Answer: B
B
Explanation:
CMI is a metric that reflects the diversity, complexity, and severity of the patients treated at a healthcare facility, such as a hospital. CMI is used by CMS to determine hospital reimbursement rates for Medicare and Medicaid beneficiaries. CMI is calculated by adding up the relative MS-DRG weight for each discharge, and dividing that by the total number of Medicare and Medicaid discharges in a given month and year. Higher CMI values indicate that a hospital has treated a greater number of complex, resource-intensive patients, and the hospital may be reimbursed at a higher rate for those cases.
However, CMI is not the best measure of CDI performance, because it is influenced by many factors beyond CDI efforts, such as patient population, coding accuracy, documentation specificity, patient comorbidities, high volumes of highly weighted DRGs, and annual updates to relative MS-DRG weights. Therefore, measuring CMI over time with a focus on particular documentation improvement areas in addition to the overall CMI can provide a more comprehensive and meaningful assessment of CDI performance. For example, CDI programs can track CMI changes for specific DRGs, clinical conditions, or service lines that are targeted for documentation improvement initiatives. This can help identify the impact of CDI interventions on documentation quality, accuracy, and completeness.
B
Explanation:
CMI is a metric that reflects the diversity, complexity, and severity of the patients treated at a healthcare facility, such as a hospital. CMI is used by CMS to determine hospital reimbursement rates for Medicare and Medicaid beneficiaries. CMI is calculated by adding up the relative MS-DRG weight for each discharge, and dividing that by the total number of Medicare and Medicaid discharges in a given month and year. Higher CMI values indicate that a hospital has treated a greater number of complex, resource-intensive patients, and the hospital may be reimbursed at a higher rate for those cases.
However, CMI is not the best measure of CDI performance, because it is influenced by many factors beyond CDI efforts, such as patient population, coding accuracy, documentation specificity, patient comorbidities, high volumes of highly weighted DRGs, and annual updates to relative MS-DRG weights. Therefore, measuring CMI over time with a focus on particular documentation improvement areas in addition to the overall CMI can provide a more comprehensive and meaningful assessment of CDI performance. For example, CDI programs can track CMI changes for specific DRGs, clinical conditions, or service lines that are targeted for documentation improvement initiatives. This can help identify the impact of CDI interventions on documentation quality, accuracy, and completeness.
Question #5
Review the following query to determine if it is compliant:
Dr. Jones, this patient had a sodium level of 126 on admission and was started on a 0.9% saline IV. Can you indicate what condition is being treated?
Dehydration
Hyponatremia
Hypernatremia
Chronic kidney disease (indicate stage)
Other (please specify)
- A . Yes, query is compliant as it offers the minimum number of multiple-choice answers ..
- B . No, query is noncompliant as it does not provide the option of "unable to determine".
- C . No, query is noncompliant as one of the multiple-choice options is clinically irrelevant.
- D . Yes, query is compliant as it provides clinical indicators and several options for response.
Correct Answer: C
C
Explanation:
A query is noncompliant if it includes options that are not supported by the clinical indicators or the patient’s condition. In this case, hypernatremia is a condition of high sodium level, not low sodium level, and it is not consistent with the treatment of 0.9% saline IV. Therefore, it is a clinically irrelevant option that may confuse or mislead the provider. A compliant query should only include options that are reasonable and plausible based on the available documentation and evidence. (CDIP Exam Preparation Guide)
References:
CDIP Exam Content Outline1
CDIP Exam Preparation Guide2
AHIMA Practice Brief: Guidelines for Achieving a Compliant Query Practice3
C
Explanation:
A query is noncompliant if it includes options that are not supported by the clinical indicators or the patient’s condition. In this case, hypernatremia is a condition of high sodium level, not low sodium level, and it is not consistent with the treatment of 0.9% saline IV. Therefore, it is a clinically irrelevant option that may confuse or mislead the provider. A compliant query should only include options that are reasonable and plausible based on the available documentation and evidence. (CDIP Exam Preparation Guide)
References:
CDIP Exam Content Outline1
CDIP Exam Preparation Guide2
AHIMA Practice Brief: Guidelines for Achieving a Compliant Query Practice3
Question #6
Several physicians at a local hospital are having difficulty providing adequate documentation on patients admitted with a diagnosis of pneumonia with or without clinical indications of gram-negative pneumonia. Subsequently, clinical documentation integrity practitioners (CDIPs) are altering health records.
Which policy and procedure should be developed to ensure compliant practice?
- A . Professional ethical standards
- B . Accreditation standards
- C . Performance standards
- D . Quality improvement standards
Correct Answer: A
A
Explanation:
A policy and procedure that should be developed to ensure compliant practice for CDIPs who are altering health records is professional ethical standards. Professional ethical standards are the principles and values that guide the conduct and decision-making of CDIPs in their role of ensuring the accuracy, completeness, and integrity of clinical documentation and coded data. According to the AHIMA Standards of Ethical Coding1 and the ACDIS Code of Ethics2, CDIPs should not alter health records without the consent or direction of the provider, as this may compromise the quality and validity of the documentation and coding, and may violate legal and regulatory requirements. CDIPs should also respect the confidentiality and security of health records, and report any unethical or fraudulent practices to the appropriate authority.
References:
CDIP® Exam Content Outline (https://www.ahima.org/media/1z0x0x1a/cdip-exam-content-outline.pdf)
AHIMA Standards of Ethical Coding1
ACDIS Code of Ethics2
A
Explanation:
A policy and procedure that should be developed to ensure compliant practice for CDIPs who are altering health records is professional ethical standards. Professional ethical standards are the principles and values that guide the conduct and decision-making of CDIPs in their role of ensuring the accuracy, completeness, and integrity of clinical documentation and coded data. According to the AHIMA Standards of Ethical Coding1 and the ACDIS Code of Ethics2, CDIPs should not alter health records without the consent or direction of the provider, as this may compromise the quality and validity of the documentation and coding, and may violate legal and regulatory requirements. CDIPs should also respect the confidentiality and security of health records, and report any unethical or fraudulent practices to the appropriate authority.
References:
CDIP® Exam Content Outline (https://www.ahima.org/media/1z0x0x1a/cdip-exam-content-outline.pdf)
AHIMA Standards of Ethical Coding1
ACDIS Code of Ethics2
Question #7
The key component of the auditing and monitoring process to ensure provider query response is to
- A . audit individual providers to indicate improvement in health record documentation
- B . have a process in place for ongoing education and training of the staff involved in conducting provider queries
- C . make sure that the language in the query is not leading or otherwise inappropriate
- D . review queries retrospectively to ensure that they are completed according to documented Policies and procedures
Correct Answer: D
Question #8
Which of the following is an appropriate first step to address physicians with low query response rates?
- A . An educational session between the clinical documentation integrity practitioner (CDIP) and physician
- B . The medical staff review the physician’s noncompliance to consider sanctions
- C . The physician receives a suspension until query responses are improved
- D . A meeting between the physician advisor/champion and the noncompliant physician
Correct Answer: A
A
Explanation:
An appropriate first step to address physicians with low query response rates is an educational session between the clinical documentation integrity practitioner (CDIP) and physician because it provides an opportunity to explain the purpose and benefits of the query process, to identify and address any barriers or challenges to responding, and to offer feedback and guidance on how to improve query response rates. An educational session can also help to build rapport and trust between the CDIP and the physician, and to demonstrate respect and professionalism. (CDIP Exam Preparation Guide)
References:
CDIP Exam Content Outline1
CDIP Exam Preparation Guide2
Understanding CDI Metrics3
A
Explanation:
An appropriate first step to address physicians with low query response rates is an educational session between the clinical documentation integrity practitioner (CDIP) and physician because it provides an opportunity to explain the purpose and benefits of the query process, to identify and address any barriers or challenges to responding, and to offer feedback and guidance on how to improve query response rates. An educational session can also help to build rapport and trust between the CDIP and the physician, and to demonstrate respect and professionalism. (CDIP Exam Preparation Guide)
References:
CDIP Exam Content Outline1
CDIP Exam Preparation Guide2
Understanding CDI Metrics3
Question #9
A 90-year-old female patient was admitted to emergency room c/o nausea and vomiting x2 days. Vital signs: BP 130/72, P 86, R 22, T 99.8F, O2 sat 94% on room air. Patient has a history of cerebral vascular accident (CVA) and difficulty swallowing. CXR revealed right lower lobe infiltrate. Labs: WBC 12.0 with 71% segs. Physician documents patient with a history of CVA and difficulty swallowing. CXR revealed right lower lobe infiltrate, diagnosis: pneumonia. Aspiration precautions and IV Clindamycin ordered. Patient was discharged 3 days later with a diagnosis of pneumonia. Clarification is needed to determine which of the following is clinically indicated.
- A . Simple pneumonia
- B . Aspiration pneumonia
- C . Pneumonia, a sequela of CVA
- D . Complex pneumonia
Correct Answer: B
B
Explanation:
Aspiration pneumonia is a type of pneumonia that occurs when food, saliva, liquids, or vomit is breathed into the lungs or airways leading to the lungs, causing an infection or inflammation. Aspiration pneumonia is more likely to occur in people who have difficulty swallowing, such as those with a history of CVA2. In this case, the patient has a history of CVA and difficulty swallowing, and presents with nausea and vomiting, which are risk factors for aspiration. The CXR reveals a right lower lobe infiltrate, which is a common finding in aspiration pneumonia3. The physician documents pneumonia as the diagnosis, but does not specify the type or cause. Therefore, clarification is needed to determine if aspiration pneumonia is clinically indicated, as it would affect the coding and reimbursement of the case. Aspiration pneumonia is coded as ICD-10-CM code J69.x Pneumonitis due to solids and liquids, with a fourth digit required to specify the inhaled substance4.
References:
CDI Week 2020 Q&A: CDI and key performance indicators1
Mayo Clinic: Aspiration pneumonia2
Medscape: Aspiration Pneumonia3
ICD-10-CM Diagnosis Code J69.x: Pneumonitis due to solids and liquids4
B
Explanation:
Aspiration pneumonia is a type of pneumonia that occurs when food, saliva, liquids, or vomit is breathed into the lungs or airways leading to the lungs, causing an infection or inflammation. Aspiration pneumonia is more likely to occur in people who have difficulty swallowing, such as those with a history of CVA2. In this case, the patient has a history of CVA and difficulty swallowing, and presents with nausea and vomiting, which are risk factors for aspiration. The CXR reveals a right lower lobe infiltrate, which is a common finding in aspiration pneumonia3. The physician documents pneumonia as the diagnosis, but does not specify the type or cause. Therefore, clarification is needed to determine if aspiration pneumonia is clinically indicated, as it would affect the coding and reimbursement of the case. Aspiration pneumonia is coded as ICD-10-CM code J69.x Pneumonitis due to solids and liquids, with a fourth digit required to specify the inhaled substance4.
References:
CDI Week 2020 Q&A: CDI and key performance indicators1
Mayo Clinic: Aspiration pneumonia2
Medscape: Aspiration Pneumonia3
ICD-10-CM Diagnosis Code J69.x: Pneumonitis due to solids and liquids4
Question #10
A 94-year-old female patient is admitted with altered mental status and inability to move the left side of her body. She is diagnosed with a cerebral vascular accident with left sided weakness. The patient is ambidextrous, but the physician does not specify the predominance of the affected side.
The default code is
- A . ambidextrous
- B . non-dominant
- C . preferred
- D . dominant
Correct Answer: B
B
Explanation:
According to the ICD-10-CM Official Guidelines for Coding and Reporting, when the affected side is not documented for a condition that is commonly associated with hemiplegia or hemiparesis, such as a cerebral vascular accident, the default code is the non-dominant side. The non-dominant side is usually the left side for right-handed individuals and the right side for left-handed individuals. However, if the patient is ambidextrous, the default code is still the non-dominant side, unless the provider indicates otherwise. Therefore, in this case, the default code for cerebral vascular accident with left sided weakness is I63.532 Cerebral infarction due to unspecified occlusion or stenosis of left middle cerebral artery1.
References:
CDIP® Exam Content Outline (https://www.ahima.org/media/1z0x0x1a/cdip-exam-content-outline.pdf)
ICD-10 Code for Cerebral infarction due to unspecified occlusion or stenosis of left middle cerebral artery- I63.532- AAPC Coder1
ICD-10-CM Official Guidelines for Coding and Reporting FY 2022
B
Explanation:
According to the ICD-10-CM Official Guidelines for Coding and Reporting, when the affected side is not documented for a condition that is commonly associated with hemiplegia or hemiparesis, such as a cerebral vascular accident, the default code is the non-dominant side. The non-dominant side is usually the left side for right-handed individuals and the right side for left-handed individuals. However, if the patient is ambidextrous, the default code is still the non-dominant side, unless the provider indicates otherwise. Therefore, in this case, the default code for cerebral vascular accident with left sided weakness is I63.532 Cerebral infarction due to unspecified occlusion or stenosis of left middle cerebral artery1.
References:
CDIP® Exam Content Outline (https://www.ahima.org/media/1z0x0x1a/cdip-exam-content-outline.pdf)
ICD-10 Code for Cerebral infarction due to unspecified occlusion or stenosis of left middle cerebral artery- I63.532- AAPC Coder1
ICD-10-CM Official Guidelines for Coding and Reporting FY 2022