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A patient with a burn wound develops sepsis as a complication. Per Guideline I.C.1.d.6, what is the principal diagnosis if both conditions meet the criteria for principal diagnosis?

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B
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2026 Statistics

Key Facts: CMDP Exam

100

Practice Questions

OpenExamPrep CMDP bank

92%

First-Attempt Pass Rate

AIHC course information (within 4 weeks of completion)

$450

Member Course Tuition

AIHC 2026

$625

Non-member Tuition

AIHC 2026

3 months

Exam Window After Course

AIHC

6 CEUs

Annual Renewal

AIHC

The AIHC CMDP credential validates clinical documentation improvement (CDI) competency. The exam is online, proctored, open-note, and taken within 3 months of completing the AIHC CDI course; tuition ($625 non-member / $450 member) includes the first attempt. CDI scope spans inpatient and outpatient/pro-fee documentation: ICD-10-CM principal and secondary diagnosis selection, MS-DRG and HCC impact, AHIMA-ACDIS compliant queries, E/M leveling, HIPAA, and clinical specificity for sepsis, respiratory failure, malnutrition, and other high-impact conditions.

Sample CMDP Practice Questions

Try these sample questions to test your CMDP exam readiness. Each question includes a detailed explanation. Start the interactive quiz above for the full 100+ question experience with AI tutoring.

1According to UHDDS, the principal diagnosis is defined as which of the following?
A.The most resource-intensive condition treated during the stay
B.The condition established after study to be chiefly responsible for occasioning the admission
C.The first diagnosis listed by the admitting physician
D.The condition with the highest reimbursement weight
Explanation: The Uniform Hospital Discharge Data Set (UHDDS) defines principal diagnosis as 'that condition established after study to be chiefly responsible for occasioning the admission of the patient to the hospital for care.' This definition is incorporated into ICD-10-CM Section II Selection of Principal Diagnosis.
2A patient is admitted with chest pain. After workup, the physician documents 'NSTEMI' as the cause. Which is the correct principal diagnosis?
A.Chest pain (R07.9)
B.NSTEMI (I21.4)
C.Acute coronary syndrome (I24.9)
D.Atherosclerotic heart disease (I25.10)
Explanation: Per ICD-10-CM Section II.A, when a symptom (chest pain) is followed by contrasting/comparative diagnoses or a confirmed diagnosis, the confirmed underlying condition is the principal diagnosis. NSTEMI is the established condition after study and is sequenced first.
3Two conditions equally meet the definition of principal diagnosis and the Alphabetic Index, Tabular List, or another coding guideline does not provide sequencing direction. According to ICD-10-CM Section II.C, which is selected as principal?
A.The condition with the higher MS-DRG weight
B.Either condition may be sequenced first
C.The condition listed first in the discharge summary
D.The condition with more clinical indicators
Explanation: ICD-10-CM Section II.C states that when two or more diagnoses equally meet the definition of principal diagnosis and no guideline directs otherwise, either condition may be sequenced first. CDI/coders should not select based on reimbursement.
4A patient with COPD is admitted for elective hip replacement. Postoperatively, the patient develops acute respiratory failure requiring ICU care. Which is the principal diagnosis?
A.Acute respiratory failure (J96.00)
B.COPD (J44.9)
C.Osteoarthritis of the hip (M16.x)
D.Postprocedural respiratory failure (J95.821)
Explanation: Osteoarthritis prompted the admission for elective surgery and meets the UHDDS definition of principal diagnosis. The acute respiratory failure occurred after admission and is a secondary diagnosis (and likely reportable as a postprocedural complication if so documented).
5A patient is admitted with sepsis due to a urinary tract infection. The UTI is identified as the localized source. Per ICD-10-CM Guideline I.C.1.d, what is the correct sequencing?
A.UTI sequenced first, sepsis as a secondary diagnosis
B.Sepsis (A41.x) sequenced first, with the UTI coded as a secondary diagnosis
C.Either condition may be sequenced first based on physician preference
D.Severe sepsis sequenced first regardless of organ dysfunction
Explanation: Per Guideline I.C.1.d.1, for a patient admitted with sepsis and a localized infection (e.g., UTI), the sepsis code is sequenced first, followed by the code for the localized infection. The exception is severe sepsis, which still requires the underlying systemic infection sequenced before R65.2x.
6Per ICD-10-CM Section II.E, when a patient is admitted for treatment of a complication resulting from surgery or other medical care, the principal diagnosis is:
A.The condition that prompted the original surgery
B.The complication code (e.g., a code from the T80-T88 range or organ-specific complication)
C.Always sequenced as Z code for status of the surgery
D.The chronic condition the surgery was meant to treat
Explanation: ICD-10-CM Section II.E states the complication code is the principal diagnosis when the admission is for treatment of the complication. If the complication code lacks needed specificity, an additional code for the specific complication may be assigned.
7Section II.D addresses 'two or more diagnoses that equally meet the definition for principal diagnosis.' Which scenario fits this rule rather than Section II.B (two or more interrelated conditions)?
A.Acute exacerbation of CHF and acute exacerbation of COPD, both treated equally
B.Pneumonia caused by bacterial infection
C.Sepsis with associated severe sepsis
D.Hypertension with chronic kidney disease
Explanation: Section II.D applies when two or more diagnoses equally meet the principal diagnosis definition and are not interrelated. Two unrelated acute decompensations both treated equally is the classic example. Section II.B applies when conditions are interrelated (e.g., manifestations of the same disease).
8A patient is admitted with abdominal pain. After study, the physician documents 'probable diverticulitis vs. gastroenteritis' at discharge in the inpatient setting. How should the principal diagnosis be coded?
A.Code only abdominal pain since neither was confirmed
B.Code one of the conditions as confirmed and use the abdominal pain as principal
C.Code the documented diagnoses as if they existed (probable conditions are coded as confirmed in the inpatient setting)
D.Query the physician but do not code anything until clarified
Explanation: Per ICD-10-CM Section II.H (inpatient setting), conditions documented at the time of discharge as 'probable,' 'suspected,' 'likely,' 'questionable,' 'possible,' or 'still to be ruled out' are coded as if they existed. This rule applies only to inpatient (short-term, acute, long-term, and psychiatric) settings, NOT outpatient.
9In the OUTPATIENT setting, how are 'probable,' 'suspected,' or 'rule out' diagnoses handled?
A.Coded as if they existed, same as inpatient
B.Coded only if confirmed by lab data
C.Not coded; instead, code the documented signs, symptoms, abnormal test results, or other reason for the visit
D.Coded with a Z03 observation code only
Explanation: Per ICD-10-CM Guideline IV.H, in the outpatient setting, do NOT code diagnoses documented as 'probable,' 'suspected,' 'questionable,' 'rule out,' or 'working diagnosis.' Instead, code the condition(s) to the highest degree of certainty (signs, symptoms, abnormal test results, or other reason for the visit). This is the opposite of the inpatient rule.
10A patient is admitted with severe sepsis due to pneumonia with associated acute kidney injury. Per Guideline I.C.1.d.1.b, what is the correct sequencing?
A.AKI, sepsis code, R65.20, pneumonia
B.Pneumonia, sepsis code, R65.20, AKI
C.Sepsis code (A41.9), R65.20 (severe sepsis), pneumonia code, AKI code
D.R65.20, pneumonia, AKI, sepsis code
Explanation: For severe sepsis, sequence the underlying systemic infection code (A41.9 sepsis) first, followed by R65.20 (severe sepsis without septic shock) or R65.21 (with septic shock), then the associated acute organ dysfunction code(s), and any localized infection. The AKI is the organ dysfunction documenting 'severe' criteria.

About the CMDP Exam

The CMDP is AIHC's clinical documentation improvement (CDI) credential for experienced HIM professionals, office nurses, coders, and documentation auditors. It validates competency in principal diagnosis selection, secondary diagnosis capture (CC/MCC), MS-DRG basics, compliant physician queries, E/M leveling under 2021/2023 revisions, HCC risk adjustment, HIPAA, and clinical specificity for high-impact conditions such as sepsis, respiratory failure, AKI/CKD, CHF, and malnutrition.

Questions

100 scored questions

Time Limit

Open-note, taken within 3 months of course completion (AIHC does not publicly publish a numeric time limit)

Passing Score

AIHC does not publicly publish a numeric passing score

Exam Fee

Included with course tuition ($625 non-member / $450 member) (American Institute of Healthcare Compliance (AIHC))

CMDP Exam Content Outline

Principal diagnosis & sequencing

ICD-10-CM Section II Principal Diagnosis Rules

UHDDS principal diagnosis definition, symptom vs. diagnosis, two or more equally meeting, complications, sepsis sequencing, and outpatient vs. inpatient uncertain-diagnosis rules.

Secondary dx & severity

CC/MCC Capture and MS-DRG

UHDDS secondary diagnosis reporting criteria, CC vs. MCC severity tiers, CC exclusions, MDC and surgical/medical splits, and relative weight impact.

Query compliance

AHIMA-ACDIS Compliant Query Practice (2022 Update)

Triggers, formats (open-ended, multiple-choice, yes/no), leading-language avoidance, required content, verbal queries, retrospective queries, and escalation.

E/M coding

E/M Leveling under 2021/2023 Revisions

Office/outpatient E/M selection by MDM (2 of 3) or total time on the date of service, and the 2023 extension to inpatient/observation, ED, nursing facility, home, and consultations.

Risk adjustment

HCC Risk Adjustment & Outpatient CDI

CMS-HCC model, MEAT documentation, hierarchies, RADV audits, and outpatient pro-fee CDI focus on chronic-condition annual capture.

Compliance & ethics

Compliance, Ethics, HIPAA

AHIMA Standards of Ethical Coding, HIPAA minimum necessary and TPO disclosures, False Claims Act, OIG Compliance Program Guidance, and denial management.

Clinical specificity

Clinical Conditions Documentation

Documentation criteria for sepsis/severe sepsis, acute respiratory failure (hypoxic and hypercapnic), AKI on CKD, CHF (acuity + type), malnutrition (ASPEN/GLIM), pneumonia, anemia, and surgical complications.

How to Pass the CMDP Exam

What You Need to Know

  • Passing score: AIHC does not publicly publish a numeric passing score
  • Exam length: 100 questions
  • Time limit: Open-note, taken within 3 months of course completion (AIHC does not publicly publish a numeric time limit)
  • Exam fee: Included with course tuition ($625 non-member / $450 member)

Keys to Passing

  • Complete 500+ practice questions
  • Score 80%+ consistently before scheduling
  • Focus on highest-weighted sections
  • Use our AI tutor for tough concepts

CMDP Study Tips from Top Performers

1Master ICD-10-CM Section II principal diagnosis rules: UHDDS definition, symptom vs. diagnosis, equally meeting cases, complications, and sepsis sequencing.
2Memorize the AHIMA-ACDIS 2022 query rules: triggers, allowed yes/no use cases, multiple-choice option requirements, and forbidden leading practices.
3Learn high-impact CC/MCC pairs (acute on chronic CHF, severe sepsis with organ dysfunction, severe malnutrition E43, acute respiratory failure) so you can spot capture opportunities.
4Practice E/M leveling under 2021 MDM rules: number/complexity of problems, data, and risk; understand the 2023 extension to inpatient, ED, and consultations.
5Drill HCC fundamentals: MEAT documentation, hierarchies, annual reset, and RADV audit risk for unsupported codes.

Frequently Asked Questions

What is the AIHC CMDP exam?

The Certified Medical Documentation Professional (CMDP) is AIHC's clinical documentation improvement credential. The exam is online, proctored, and open-note. It is taken within 3 months of completing the required AIHC CDI course.

How much does the AIHC CMDP exam cost?

The CMDP course tuition is $625 for non-members and $450 for AIHC members, and the first exam attempt is included if taken within 3 months of course completion. AIHC has not separately published a stand-alone exam fee.

What is the CMDP passing score and pass rate?

AIHC does not publish a numeric passing score for the CMDP exam. AIHC reports an approximate 92% first-attempt pass rate when the exam is taken within 4 weeks of completing the course.

What does the CMDP exam cover?

Topics include ICD-10-CM principal diagnosis selection, secondary diagnosis (CC/MCC) capture, MS-DRG basics, compliant physician queries (AHIMA-ACDIS 2022), E/M coding (2021/2023 revisions), HCC risk adjustment, HIPAA and AHIMA ethics, and clinical documentation specificity for conditions such as sepsis, respiratory failure, AKI/CKD, CHF, and malnutrition.

How is the CMDP credential maintained?

The CMDP credential renews annually and requires 6 continuing education units (CEUs) per year through AIHC-approved activities.

Who should pursue the CMDP credential?

AIHC designs the CMDP for experienced HIM professionals, office nurses (RN, LPN), professional coders, professional documentation auditors, and other qualified staff already working with provider documentation.

How many attempts are allowed for the CMDP exam?

Candidates may take up to 3 attempts within 1 year of course enrollment. The first attempt is included with course tuition; up to 2 additional attempts may be purchased.