Certified Documentation Improvement Professional (CDIP)

Objectives

By the end of the course, participants will be able to:

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

Course Modules

1. Introduction to Clinical Documentation Improvement (CDI)
   • Definition, scope, and significance
   • Key principles and evolving trends
2. Clinical and Coding Knowledge
   • Medical terminology and disease processes
   • ICD-10-CM and ICD-10-PCS coding systems
   • CPT and DRG groupers
3. Record Review and Query Process
   • CDI query guidelines and AHIMA best practices
   • Clinical indicators and documentation analysis
   • Writing compliant physician queries
4. Regulatory and Reporting Requirements
   • CMS and The Joint Commission documentation standards
   • Quality reporting (e.g., HEDIS, Core Measures, Risk Adjustment)
   • HIPAA and legal considerations
5. Healthcare Data Quality and Metrics
   • Data analysis and reconciliation
   • DRG validation and audit preparation
   • CDI program metrics and dashboards
6. Communication and Collaboration
   • Physician engagement strategies
   • Interdepartmental teamwork
   • Educating providers on documentation requirements
7. Exam Readiness and Case-Based Practice
   • Practice tests, Q&A review
   • CDI case studies
   • Time management strategies for the exam