CDIP(Certified Documentation Improvement Practitioner) Certification


CDIP (Certified Documentation Improvement Practitioner) Certification

  • The Clinical Documentation Improvement Practitioner
  • (CDIP) certification is a professional credential awarded to individuals who specialize in improving the quality and accuracy of clinical documentation in healthcare settings.
  • The certification is offered by the American Health Information Management Association (AHIMA).

Eligibility Requirements (For up to date info kindly refer AHIMA website)

  • Candidates must meet one of the following eligibility requirements to sit for the CDIP® examination:
  • Hold an associate’s degree or higher; or
  • Hold a CCS®, CCS-P®, RHIT®, or RHIA®credential
  • While not required, the following are recommended:
  • Minimum of two (2) years of clinical documentation integrity experience
  • Associate’s degree or higher in a health care or allied health care discipline
  • Completion of coursework in the following topics:
  • Medical terminology
  • Human anatomy and physiology
  • Pathology
  • Pharmacology 

CDIP Course Domain

  • Domain 1 – Clinical Coding Practice
  • Domain 2 – Education and Leadership Development
  • Domain 3 – Record Review & Document Clarification
  • Domain 4 – CDI Metrics & Statistics
  • Domain 5 – Compliance

Detailed CDIP curriculum:

Domain 1 – Clinical Coding Practice (15-18%)


  • Use reference resources for code assignment
  • Identify the principal and secondary diagnoses in order to accurately reflect the patient’s 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

Domain 2 – Education and Leadership Development (21-26%)


  • 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 topics 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

Domain 3 – Record Review & Document Clarification (27-33%)


  • 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

Domain 4 – CDI Metrics & Statistics (8-11%)


  • 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

Domain 5 – Compliance (18-23%)


  • 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


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