Welcome to AGES Coding TECH — your gateway to a successful career in Medical Coding. This presentation covers the five core domains of Clinical Documentation Integrity (CDI) practice, along with everything you need to know about enrolling in our world-class Medical Coding Training Programs.
The CDI professional's body of knowledge is organized into five domains, each carrying a specific weight on the certification exam. Together, they define the full scope of competency required for excellence in Clinical Documentation Integrity.
Clinical Coding Practice
Education & Leadership Development
Record Review & Document Clarification
CDI Metrics & Statistics
Compliance
Domain 3 (Record Review & Document Clarification) carries the highest weight at 27–33%, reflecting its central role in day-to-day CDI practice. Domain 2 (Education & Leadership) follows closely at 21–26%, underscoring the importance of organizational influence and team development.
Clinical Coding Practice forms the technical foundation of CDI work. Professionals must demonstrate proficiency across the full coding workflow — from reference resource use through final DRG assignment and communication with HIM staff.
Use authoritative reference resources to accurately assign diagnosis and procedure codes, applying all relevant coding conventions and official guidelines.
Identify and correctly sequence the principal diagnosis and all secondary diagnoses to accurately reflect the complete patient hospital course.
Understand the assignment of both the working DRG and the final DRG, recognizing how code selection drives reimbursement outcomes.
Communicate with coding and HIM staff to resolve discrepancies between working and final DRGs, and ensure coding and reimbursement updates are incorporated into ongoing practice.
This domain — the second largest on the exam — reflects the CDI professional's responsibility to drive organizational change, build collaborative relationships, and develop the policies and educational frameworks that sustain a high-performing CDI program.
Promote CDI efforts throughout the organization and health system, including administration. Create and nurture working relationships to support collaboration across multi-disciplinary teams. Collaborate with physician champions to advance CDI initiatives at all levels.
Develop CDI policies and procedures in accordance with AHIMA practice briefs. Determine facility requirements for documentation of query responses in the record. Establish official policy and procedures related to CDI query activities. Recognize a chain of command for resolving unanswered queries.
Develop documentation improvement projects. Identify educational topics and delivery methods for effective learning tailored to specific audiences. Articulate the implications of accurate documentation and coding with respect to research, public health reporting, case management, and reimbursement.
This is the largest domain on the CDI exam and the heart of daily CDI practice. It encompasses the full lifecycle of health record review — from case identification and gap analysis through query development, provider interaction, and post-discharge follow-up.
Demonstrate thorough comprehension of clinical documentation in health records, including disease processes, clinical concepts, and clinical validation opportunities.
Identify and prioritize cases as part of the CDI review process to maximize impact on quality of care, code assignment, and reimbursement.
Identify gaps in documentation that may impact patient quality of care, code assignment, or reimbursement — including POA status, acuteness/chronicity, complications, and comorbidities.
Apply industry current best practices pertaining to query development and query processes. Identify strategies for obtaining query responses from providers and ensure responses are documented in the health record.
Interact with providers to clarify documentation opportunities including patient quality indicators, POA, acuteness/chronicity, and complications. Identify post-discharge query opportunities to ensure complete and accurate records.
Although the smallest domain by exam weight, CDI Metrics & Statistics is critical for demonstrating departmental value, driving continuous improvement, and benchmarking performance against industry standards. CDI professionals must be fluent in data interpretation and workflow optimization.
Identify common dashboard metrics and continuously monitor CDI departmental performance against established targets and benchmarks.
Perform quality audits of CDI content to ensure compliance with institutional policies, procedures, and national guidelines.
Track metrics and interpret trends related to the physician query process, including CDI perspective vs. provider perspective analysis.
Track and interpret data for physician benchmarking and trending. Compare institution with external benchmarks. Use CDI data to adjust and optimize departmental workflow.
Compliance is the second-largest domain and reflects the ethical and regulatory responsibilities of every CDI professional. From AHIMA standards to technology risk management and query compliance, this domain ensures CDI practice remains defensible, ethical, and audit-ready.
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 including electronic health records (EHR), natural language processing (NLP), and computer-assisted coding (CAC). Understand 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 query stages, time frames, and retention to avoid compliance risk.
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Understanding the relative weight of each domain helps you prioritize your study efforts. Domain 3 commands the most attention, followed by Domain 2 and Domain 5.
Domain 3 (Record Review & Document Clarification) at 27–33% is the single most heavily tested area, making query development, provider interaction, and documentation gap identification the most critical skills to master. Domain 2 (Education & Leadership) and Domain 5 (Compliance) together account for nearly half the exam.
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The CDIP exam is offered by AHIMA with pricing that varies based on membership status. Review the options below to find the best fit for you.
140 (106 scored + 34 pretest)
3 Hours
Same as original exam fee
This domain evaluates a coder's ability to accurately assign, sequence, and validate diagnosis and procedure codes while adhering to official guidelines and collaborating with clinical and HIM staff. It covers the full spectrum of inpatient coding — from identifying principal diagnoses to resolving DRG discrepancies — making it one of the most technically rigorous domains on the CDIP exam. A strong command of coding conventions, reference tools, and reimbursement logic is essential to performing well in this domain.
Leverage key coding reference tools — including ICD-10-CM, ICD-10-PCS, CPT, and AHIMA coding guidelines — to ensure accurate and compliant code assignment. Familiarity with Coding Clinic advisories and AHA guidance is equally important for resolving ambiguous coding scenarios. Coders must stay current with annual updates to code sets and guidelines, as changes can directly impact DRG assignment and reimbursement outcomes.
Accurately determine and document the principal diagnosis in accordance with UHDDS definitions — the condition established after study to be chiefly responsible for the admission. Secondary diagnoses, including comorbidities and complications (CCs and MCCs), must also be captured comprehensively, as they significantly influence DRG weight and reimbursement. Correct identification and sequencing of all diagnoses ensures the coded record reflects the full clinical complexity of the patient's hospital course.
Apply correct sequencing logic when assigning diagnosis and procedure codes in strict accordance with ICD-10-CM/PCS Official Guidelines and facility-specific policies. Accurate sequencing is critical not only for compliance but also for reimbursement accuracy, as the principal diagnosis drives DRG grouping and payment. Coders must also apply Present on Admission (POA) indicators appropriately, as these affect hospital-acquired condition (HAC) reporting and quality metrics.
Adhere to established ICD-10-CM Official Guidelines, including the correct use of inclusion and exclusion notes, default codes, and combination codes. Pay particular attention to Excludes1 and Excludes2 notes, which govern whether two codes can be reported together and carry significant compliance implications. Coding Clinic guidance issued by the AHA serves as the authoritative source for resolving coding questions and should be referenced regularly alongside the official guidelines.
Demonstrate proficiency in the assignment of both working and final Diagnosis-Related Groups (DRGs), understanding how each is determined at different points in the patient encounter. The working DRG is assigned at or near admission based on the preliminary diagnosis, while the final DRG is determined at discharge after all diagnoses and procedures are coded. The presence of CCs and MCCs can significantly elevate DRG weight, directly impacting reimbursement — making accurate capture of these conditions a high-stakes coding responsibility.
Collaborate with CDI specialists, coding staff, and HIM professionals to identify and resolve discrepancies between working and final DRGs through structured query and reconciliation workflows. The physician query process is a key tool for clarifying documentation gaps that affect code assignment, ensuring the coded record accurately reflects clinical intent and supports appropriate reimbursement. Unresolved discrepancies can negatively impact the facility's Case Mix Index (CMI), making timely and thorough reconciliation critical to both compliance and financial performance.
This domain is the second largest on the CDIP exam and reflects the CDI professional's responsibility to lead organizational change, foster interdisciplinary collaboration, and build a culture of documentation excellence. It goes beyond clinical knowledge to test leadership, communication, and policy development skills. Mastery of this domain requires understanding how CDI initiatives are promoted, sustained, and measured across the health system.
Advocate for CDI initiatives across all levels of the organization, including clinical departments, administration, and executive leadership. Effective promotion requires clear communication of CDI's impact on quality metrics, reimbursement, and compliance. CDI professionals must be able to present data-driven outcomes to gain buy-in from stakeholders at every level.
Develop and nurture working relationships with physicians, nurses, coders, case managers, and other multidisciplinary team members to support a unified approach to documentation improvement. Strong interpersonal skills and trust-building are essential for sustaining long-term CDI program success. Collaboration across departments ensures that documentation gaps are identified and addressed proactively.
Design, implement, and evaluate targeted documentation improvement projects based on identified gaps in clinical records. Projects may focus on specific diagnosis categories, service lines, or provider groups with recurring documentation deficiencies. Outcomes should be tracked using measurable metrics and reported to leadership regularly.
Partner with physician champions to promote CDI initiatives, drive provider engagement, and model best practices in clinical documentation. Physician champions serve as peer influencers who can communicate the importance of accurate documentation in clinical terms that resonate with their colleagues. CDI professionals must support and equip these champions with data, education, and query feedback.
Create and maintain CDI policies and procedures in alignment with AHIMA practice briefs, official guidelines, and facility-specific requirements. Well-defined policies ensure consistency in query practices, record review workflows, and staff responsibilities. Policies should be reviewed and updated regularly to reflect changes in regulations, coding guidelines, and organizational priorities.
Determine facility requirements for the documentation of query responses in the health record, and establish official policies governing CDI query activities. This includes defining compliant query formats, response timelines, and escalation procedures. Clear query policies protect the organization from compliance risk and ensure that physician responses are captured accurately and consistently.
Identify and apply the appropriate chain of command when queries go unanswered or unresolved within established timeframes. Escalation pathways may involve department heads, physician champions, compliance officers, or medical staff leadership. A structured escalation process ensures that documentation gaps do not persist and that reimbursement and quality reporting are not compromised.
Identify educational topics and select appropriate delivery methods to effectively train physicians, coders, and CDI staff on documentation best practices. Education should be tailored to the audience — clinical staff benefit from case-based learning, while administrative staff may respond better to outcome-focused presentations. Ongoing education is critical to sustaining CDI program performance and adapting to evolving coding and regulatory requirements.
Communicate the downstream impact of precise clinical documentation on research, public health reporting, case management, quality scores, and reimbursement. CDI professionals must be able to translate complex coding and financial concepts into language that resonates with clinicians and administrators alike. Understanding these implications reinforces the value of CDI across the entire health system.
As the largest domain on the CDIP exam, Record Review & Document Clarification sits at the heart of CDI practice. It tests the professional's ability to critically analyze health records, identify documentation gaps, and engage providers through compliant and effective query processes. Success in this domain requires a deep command of clinical concepts, disease processes, and industry-standard query best practices.
Demonstrate thorough comprehension of clinical documentation in health records, including disease processes, clinical indicators, and the relationship between diagnoses and treatment plans. CDI professionals must be able to interpret physician notes, operative reports, lab values, and diagnostic findings to assess the completeness and accuracy of the record. A strong clinical knowledge base is essential for identifying when documentation does not fully reflect the patient's condition or the care provided.
Apply systematic criteria to identify and prioritize cases for CDI review, focusing on high-impact admissions such as those with complex diagnoses, high-cost procedures, or significant reimbursement implications. Prioritization strategies may include DRG-based triggers, length-of-stay outliers, or service-line-specific review queues. Efficient case selection ensures that CDI resources are directed where they will have the greatest clinical and financial impact.
Recognize gaps in clinical documentation that may affect patient quality of care, code assignment, or reimbursement — including missing diagnoses, unsupported clinical validation, unclear acuity, or absent specificity. CDI professionals must apply knowledge of CC/MCC capture, clinical validation principles, and quality indicator requirements to flag deficiencies accurately. Identifying these gaps early in the encounter allows for timely provider engagement and reduces the need for post-discharge queries.
Develop and execute physician queries in accordance with AHIMA and ACDIS industry guidelines, ensuring queries are compliant, non-leading, and clinically supported. Best practices include using multiple-choice or open-ended formats, providing relevant clinical indicators, and avoiding language that suggests a preferred response. Adherence to query standards protects the organization from compliance risk and ensures the integrity of the coded record.
Implement strategies to obtain timely query responses from providers and ensure that all responses are properly documented in the health record in accordance with facility policy. Follow-up workflows, provider education, and escalation protocols are key tools for improving query response rates. Documented responses must be clinically consistent and support the final code assignment to withstand audit scrutiny.
Engage directly with physicians and other providers to clarify documentation opportunities related to patient quality indicators, Present on Admission (POA) status, acuteness vs. chronicity of conditions, complications, and comorbidities. Effective provider interaction requires strong communication skills, clinical credibility, and a collaborative — rather than adversarial — approach. These conversations are the cornerstone of CDI practice and directly influence the accuracy of the final coded record.
Recognize situations where documentation gaps identified after patient discharge warrant a retrospective query to the provider. Post-discharge queries must follow the same compliance standards as concurrent queries and should be initiated promptly to minimize delays in billing and reimbursement. CDI professionals must balance the need for accurate documentation with the time-sensitive nature of the revenue cycle.
This domain focuses on the CDI professional's ability to measure, monitor, and act on departmental performance data. From dashboard metrics to physician benchmarking, it tests your capacity to use data as a tool for continuous improvement and compliance.
Track key CDI performance indicators through departmental dashboards to identify trends and opportunities for improvement.
Perform regular audits of CDI content to ensure alignment with institutional policies, procedures, and national guidelines.
Monitor and interpret trends in the physician query process, including CDI perspective vs. provider perspective response patterns.
Collect and analyze provider-level data to identify documentation patterns, outliers, and opportunities for targeted education.
Compare your institution's CDI performance against external benchmarks to assess competitiveness and identify best practices.
Define and track the core KPIs used to evaluate CDI professional performance, including query rate, response rate, and case mix impact.
Use CDI data insights to refine and optimize departmental workflows, staffing priorities, and review strategies.
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