CDIP EXAM 2026 COMPLETE CLINICAL
DOCUMENTATION IMPROVEMENT PRACTICE
AND REVISION NOTES
◉ Sdx.
Answer: secondary dx
◉ NOS.
Answer: not otherwise specified
◉ POA.
Answer: present on admission
◉ LOS.
Answer: length of stay
◉ SOI.
Answer: severity of illness
◉ Rom.
Answer: risk of mortality
,◉ NEC.
Answer: not elsewhere classifiable
◉ DRG.
Answer: diagnosis related groups
◉ MDC.
Answer: major diagnostic category .
◉ CC.
Answer: complication & comorbidity
◉ SDOH.
Answer: Social determinants of Health
◉ ROI.
Answer: return on investment
◉ NLP.
Answer: natural language processing
,◉ CPT.
Answer: Current Procedural Terminology
◉ HCPCS.
Answer: Healthcare Common Procedure Coding System
◉ O/E.
Answer: observed to expected mortality ratio
◉ ICD-10-PCS codes.
Answer: 7 characters in length
◉ CPT codes are owned by:.
Answer: The AMA.
5 characters in length , are all # ' s or numbers with a letter as the
5th character
◉ CPT codes three categories.
Answer: Category 1 describe ( procedures , devices common ,
medicine services , & provideines ) . Contains all # Category II - used
as supplemental tracking for quality & performance measures -
alphanumeric with 4 # ' s and an " F " as the 5th character .
, Category III Temporary codes used for new and emerging
technology . Alphanumeric & 4 #s and a " T " as the 5th character
◉ HCPCS Codes.
Answer: developed by the HHS for reimbursement of services
provided to medicare & medicaid beneficiaries that were not
described by CPT codes .
◉ HCPCS categories.
Answer: Level I - Category | CPT codes and are maintained by the
AMA Level II used to report services not described in the Category I
CPT code set .
◉ 7 Characteristics of high-quality documentation.
Answer: Clear
Precise
Reliable
Consistent
Legibility
Complete
Timely
◉ SOI/ROM.
DOCUMENTATION IMPROVEMENT PRACTICE
AND REVISION NOTES
◉ Sdx.
Answer: secondary dx
◉ NOS.
Answer: not otherwise specified
◉ POA.
Answer: present on admission
◉ LOS.
Answer: length of stay
◉ SOI.
Answer: severity of illness
◉ Rom.
Answer: risk of mortality
,◉ NEC.
Answer: not elsewhere classifiable
◉ DRG.
Answer: diagnosis related groups
◉ MDC.
Answer: major diagnostic category .
◉ CC.
Answer: complication & comorbidity
◉ SDOH.
Answer: Social determinants of Health
◉ ROI.
Answer: return on investment
◉ NLP.
Answer: natural language processing
,◉ CPT.
Answer: Current Procedural Terminology
◉ HCPCS.
Answer: Healthcare Common Procedure Coding System
◉ O/E.
Answer: observed to expected mortality ratio
◉ ICD-10-PCS codes.
Answer: 7 characters in length
◉ CPT codes are owned by:.
Answer: The AMA.
5 characters in length , are all # ' s or numbers with a letter as the
5th character
◉ CPT codes three categories.
Answer: Category 1 describe ( procedures , devices common ,
medicine services , & provideines ) . Contains all # Category II - used
as supplemental tracking for quality & performance measures -
alphanumeric with 4 # ' s and an " F " as the 5th character .
, Category III Temporary codes used for new and emerging
technology . Alphanumeric & 4 #s and a " T " as the 5th character
◉ HCPCS Codes.
Answer: developed by the HHS for reimbursement of services
provided to medicare & medicaid beneficiaries that were not
described by CPT codes .
◉ HCPCS categories.
Answer: Level I - Category | CPT codes and are maintained by the
AMA Level II used to report services not described in the Category I
CPT code set .
◉ 7 Characteristics of high-quality documentation.
Answer: Clear
Precise
Reliable
Consistent
Legibility
Complete
Timely
◉ SOI/ROM.
