Certified Documentation Improvement Professional (CDIP) Certification Training

Credentialing Body: AHIMA – American Health Information Management Association

The CDIP certification is designed for professionals who ensure clinical documentation accurately reflects patient care, supports medical necessity, and complies with regulatory standards. This comprehensive CDIP certification training focuses on clinical documentation improvement strategies, ICD-10-CM coding, DRG optimization, and fostering collaboration between clinicians and coding teams. It is ideal for those preparing for the AHIMA CDIP certification exam and aiming to become a Certified Documentation Improvement Practitioner.

Objectives

  • Understand the goals and impact of clinical documentation improvement (CDI).
  • Interpret clinical language and documentation to support accurate coding.
  • Identify documentation gaps and recommend improvements.
  • Collaborate effectively with physicians, coders, and compliance teams.
  • Prepare for the CDIP certification exam administered by AHIMA.

Target Audience

  • Clinical Documentation Specialists
  • Health Information Management (HIM) Professionals
  • Registered Nurses (RNs) and Clinical Reviewers
  • Medical Coders and Compliance Officers
  • CDI Program Coordinators
  • Physicians and Physician Advisors involved in documentation

Course Modules

Introduction to Clinical Documentation Improvement (CDI)

  • Definition, scope, and significance
  • Key principles and evolving trends

Clinical and Coding Knowledge

  • Medical terminology and disease processes
  • ICD-10-CM and ICD-10-PCS coding systems
  • CPT and DRG groupers

Record Review and Query Process

  • CDI query guidelines and AHIMA best practices
  • Clinical indicators and documentation analysis
  • Writing compliant physician queries

Regulatory and Reporting Requirements

  • CMS and The Joint Commission documentation standards
  • Quality reporting (e.g., HEDIS, Core Measures, Risk Adjustment)
  • HIPAA and legal considerations

Healthcare Data Quality and Metrics

  • Data analysis and reconciliation
  • DRG validation and audit preparation
  • CDI program metrics and dashboards

Communication and Collaboration

  • Physician engagement strategies
  • Interdepartmental teamwork
  • Educating providers on documentation requirements

Exam Readiness and Case-Based Practice

  • Practice tests, Q&A review
  • CDI case studies
  • Time management strategies for the exam

Program Benefits

Individual Benefits

  • Validates expertise in improving documentation integrity
  • Increases value as a cross-functional resource (clinical + coding)
  • Opens career paths in hospitals, insurance firms, and consultancies
  • Enhances leadership opportunities within CDI teams
  • Increases earning potential and job stability

Organizational Benefits

  • Improves accuracy of patient records and quality scores
  • Enhances DRG assignments and reimbursement
  • Strengthens audit readiness and legal compliance
  • Encourages cross-functional collaboration between clinical and coding teams
  • Reduces claim denials due to poor or insufficient documentation

Eligibility Criteria

  • An RHIA, RHIT, CCS, CCS-P, RN, MD, or DO credential, or
  • A Bachelor’s degree or higher + 2 years of clinical documentation integrity (CDI) experience, or
  • An Associate degree + 3 years of CDI experience
  • Relevant experience in coding, clinical documentation, or medical record auditing is a must.

Exam Details

  • Administered by: AHIMA
  • Format: 140 multiple-choice questions (130 scored, 10 unscored)
  • Duration: 3.5 hours
  • Passing Score: 300 (on a scale of 100–400)
  • Recertification: Every 2 years (20 CEUs required)