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Commission on Certification for Health Informatics

and Information Management (CCHIIM)


Candidate Guide

Registered Health Information Administrator (RHIA®)


Registered Health Information Technician (RHIT®)
Certified Coding Associate (CCA®)
Certified Coding Specialist (CCS®)
Certified Coding Specialist—Physician-based(CCS-P®)
Certified Health Data Analyst (CHDA®)
Certified in Healthcare Privacy and Security (CHPS®)
Certified Documentation Improvement Practitioner (CDIP®)
Certified Healthcare Technology Specialist (CHTS)
Certified Professional in Health Informatics (CPHI)

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Updated June 27, 2017


ahima.org
Updated June 27, 2017
CONTACT INFORMATION

AHIMA
Customer Relations Phone: (800) 335-5535
Fax: (312) 233-1500

Submit Exam Applications and Fees: Certification Examinations


AHIMA
Dept. 77-3081
Chicago, IL 60678-3081

Submit HIT and HIA Transcripts: Mailed to:


Certification Transcripts
AHIMA
233 N. Michigan Ave., 21st Fl.
Chicago, IL 60601
OR
Sent electronically to (if this option is available,
vendor information is provided by your school):
CertificationTranscripts@ahima.org

Appeals: Commission on Certification Appeals


AHIMA
233 N. Michigan Ave., 21st Fl.
Chicago, IL 60601

Complaints: Commission on Certification Complaints


AHIMA
233 N. Michigan Ave., 21st Fl.
Chicago, IL 60601

Pearson Vue Scheduling: (888) 524-4622

Updated June 27, 2017


TABLE OF CONTENTS
ABOUT THE CANDIDATE GUIDE Identification Requirements . . . . . . . . . . . . . . . . . . . . . 12
Introduction. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 Test Center Restrictions. . . . . . . . . . . . . . . . . . . . . . . . . 12
About CCHIIM. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 Security. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13
About AHIMA. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3 Misconduct. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13
Cancellation Due to Bad Weather or
VALUE OF CERTIFICATION Other Emergencies . . . . . . . . . . . . . . . . . . . . . . . . . . . 13
AHIMA-Certified Professionals Deliver the Results Medical or Personal Emergency. . . . . . . . . . . . . . . . . . 13
Your Organization Needs . . . . . . . . . . . . . . . . . . . . . . . . 3
AFTER THE EXAMINATION
Professional Certification through AHIMA. . . . . . . . . 3
Notification of Examination Results. . . . . . . . . . . . . . 13
ABOUT CERTIFICATION . . . . . . . . . . . . . . . . . . . . 4 Confidentiality Procedures. . . . . . . . . . . . . . . . . . . . . . 13
Validation of Scores. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14
ABOUT AHIMA CREDENTIALS
Release of Information. . . . . . . . . . . . . . . . . . . . . . . . . . 14
Registered Health Information Certificates . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14
Administrator (RHIA) . . . . . . . . . . . . . . . . . . . . . . . . . 4 Examination Complaints. . . . . . . . . . . . . . . . . . . . . . . . 14
Registered Health Information Technician (RHIT) . . 5 Re-taking the Examination and Process. . . . . . . . . . . 14
Certified Coding Associate (CCA). . . . . . . . . . . . . . . . . 5 Use of the Credential. . . . . . . . . . . . . . . . . . . . . . . . . . . . 14
Certified Coding Specialist (CCS). . . . . . . . . . . . . . . . . 6 Registry. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14
Certified Coding Specialist— Credential Verification. . . . . . . . . . . . . . . . . . . . . . . . . . 14
Physician-based (CCS-P). . . . . . . . . . . . . . . . . . . . . . . . 6
Certified Health Data Analyst (CHDA) . . . . . . . . . . . . 6 APPENDICES
Certified in Healthcare Privacy and Security (CHPS). . . 7 Appendix A: AHIMA Membership Application. . . . 15
Certified Documention Improvement Appendix B: Authorization to Test Letter . . . . . . 17–18
Practitioner (CDIP). . . . . . . . . . . . . . . . . . . . . . . . . . . . 7 Appendix C: Sample Pass and Fail
Certified Healthcare Technology Specialist (CHTS). . 7 Score Report . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19–20
Certified Professional in Health Informatics (CPHI). . . 8 Appendix D: Sample Test Completion Notice . . . . . . 21
Appendix E: Scale Scoring FAQs . . . . . . . . . . . . . . . . . 22
APPLYING FOR THE EXAM Appendix F: AHIMA Accommodations under
Submitting an Application. . . . . . . . . . . . . . . . . . . . . . . . 8 the ADA Policies and Procedures . . . . . . . . . . . . . . . 23
Incomplete Applications. . . . . . . . . . . . . . . . . . . . . . . . . . 8 Appendix G: Registered Health Information
Independent Testing Agency. . . . . . . . . . . . . . . . . . . . . . 8 Administrator (RHIA) Examination
Content Outline. . . . . . . . . . . . . . . . . . . . . . . . . . . 24–26
TEST TAKERS’ RIGHTS AND RESPONSIBILITIES. . . 9 Appendix H: Registered Health Information
Technician (RHIT) Examination
AHIMA EXAM APPLICATION CHECKLIST. . . . . . . 9 Content Outline. . . . . . . . . . . . . . . . . . . . . . . . . . . 27–29
SCHEDULING THE EXAMINATION Appendix I: Certified Coding Associate (CCA)
Examination Content Outline. . . . . . . . . . . . . . . 30–31
Authorization to Test (ATT) Letters . . . . . . . . . . . . . . 10
Appendix J: Certified Coding Specialist (CCS)
Scheduling an Appointment to Test. . . . . . . . . . . . . . . 10 Examination Content Outline. . . . . . . . . . . . . . . 32–33
Test Centers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10 Appendix K: Certified Coding Specialist—
APPOINTMENT CHANGES Physician-Based (CCS-P) Examination
Content Outline. . . . . . . . . . . . . . . . . . . . . . . . . . . 34–35
Policy on Cancelling or Rescheduling. . . . . . . . . . . . . 10 Appendix L: Certified Health Data Analyst
Refund Policy. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10 (CHDA) Examination Content Outline. . . . . . . . . . 36
Penalties . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11 Appendix M: Certified in Healthcare Privacy
and Security (CHPS) Examination
ELIGIBILITY EXTENSION FEE AND POLICY. . . . . 11
Content Outline. . . . . . . . . . . . . . . . . . . . . . . . . . . 37–38
PREPARING FOR THE EXAM Appendix N: Certified Documentation Improvement
Practitioner (CDIP) Examination
Tips for Success. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11 Content Outline. . . . . . . . . . . . . . . . . . . . . . . . . . . 39–40
ON EXAMINATION DAY Appendix O: Certified Professional in Health
Informatics (CPHI) Examination . . . . . . . . . . . . 41–42
Examination Procedures. . . . . . . . . . . . . . . . . . . . . . . . 11

AHIMA CERTIFICATION CANDIDATE GUIDE Updated June 27, 2017 1


ABOUT THE CANDIDATE GUIDE

Introduction and relevant body of HIIM competencies (also referred to


as knowledge, skills, and abilities). The subject matter
Congratulations on your decision to earn an American
(also referred to as a body of knowledge, or BoK for short)
Health Information Management Association (AHIMA)
represented by these competencies is further segmented
credential. We commend your commitment to your career
across specific roles and disciplines throughout the HIIM
and the health informatics and information management
profession as a whole by the requisite levels of depth,
(HIIM) profession.
breadth, and experiences necessary for successful job
This guide includes information about: performance, as exemplified by each respective AHIMA
• Eligibility qualifications certification.
• Guidelines for applying for and scheduling the About CCHIIM Exam Development
examination Committees (EDC)
• What to expect at the test center CCHIIM EDCs are comprised of experienced, credential-
• What to expect after completing the examination specific subject matter experts, representing HIIM leaders,
practitioners, and other relevant stakeholders. EDCs are
About the Commission on Certification responsible for the specific oversight and performance of
their respective credential’s certification examination. EDC
for Health Informatics and Information responsibilities are codified in the CCHIIM operating code,
Management (CCHIIM) and typically include recurring review of content relevancy,
Purpose both item-level and examination-level performance data,
and expertise with respect to establishing the cut score for
CCHIIM serves the public by establishing, implementing, their respective certification examinations.
and enforcing standards and procedures for certification
and recertification of health informatics and information Job Analysis
management (HIIM) professionals. The job analysis process ensures quality control of the
CCHIIM Mission relevancy, currency, and validity of the competencies
assessed by each certification examination. Job analyses
Through certification, the CCHIIM ensures the are typically performed every three to five years; however,
competency of professionals practicing health infomatics CCHIIM plans for and conducts comprehensive job
and information management (HIIM) worldwide. analyses according to the rate and amount of changes
CCHIIM Vision taking place within a given certification examination.
Consistent with best practices, the task of job analysis is
Professional excellence in health infomatics and information
overseen by a diverse and representative sample of
management (HIIM) through certification.
stakeholders, including recently certified professionals
CCHIIM Values and employers/supervisors. These stakeholders assess the
• The application of evidence-based best practices for criticality of current workplace practices, skills, tasks, and
certification; responsibilities, with respect to the importance and
frequency of performance. The results of the job analysis
• The validation of workforce competence through influence to what extent the competencies are revised for
professional certification; each certification examination.
• The commitment to ongoing professional development,
lifelong learning, and workforce excellence; and Examination Blueprints and Specifications
• The recognition of CCHIIM-certified professionals’ role The job analysis serves as the foundation for the exami-
in maintaining and enhancing quality health informa- nation blueprint. First, the individual competencies are
tion for the safety of the public and the improvement of grouped into domains that represent specific and similar
healthcare. areas of content. Next, the percentage weighting of each
content domain is determined, in part, through the indi-
CCHIIM Exam Development Process: vidual competency statement criticality scores, considered
An Overview for Stakeholders collectively, within each domain. This weighting of
AHIMA/CCHIIM certification exams are valid, reliable, domains relative to one another allows the EDCs to deter-
and legally defensible assessment instruments that measure mine how much, or to what extent, each domain is assessed
the competency of potential certificants against a codified (both by the number and difficulty of test items), relative to

2 Updated June 27, 2017 AHIMA CERTIFICATION CANDIDATE GUIDE


the other domains. For example, domains with competen- settings. Since 1932, AHIMA has certified HIIM profes-
cies with higher criticality scores (that is more important sionals through its rigorous testing standard.
and/or more frequently performed) typically represent a AHIMA currently sponsors the following certification
larger percentage of test items than those domains with examinations:
lower criticality scores for their respective competencies.
Registered Health Information Administrator (RHIA)
The examination specifications are typically established or
Registered Health Information Technician (RHIT)
revised at the same time as the development of the exami-
nation blueprint. The specifications usually include the Certified Coding Associate (CCA)
total number of test items (both scored and non-scored), Certified Coding Specialist (CCS)
test item type(s), such as multiple-choice or other, total test
Certified Coding Specialist—Physician-based (CCS-P)
duration, and scoring methodology.
Certified Health Data Analyst (CHDA)
For additional information on CCHIIM, please visit
ahima.org/certification/cchiim. Certified in Healthcare Privacy and Security (CHPS)
Certified Documentation Improvement Practitioner
About AHIMA (CDIP)
AHIMA is a professional association composed of 52 Certified Healthcare Technology Specialist (CHTS)
component state associations and more than 103,000 health Certified Professional in Health Informatics (CPHI)
information professionals who work in various healthcare

VALUE OF CERTIFICATION

AHIMA-Certified Professionals Deliver Certified for Success


the Results Your Organization Needs Organizations that employ credentialed HIIM
professionals can expect the highest levels of competency.
Setting the standard since 1932 as the leader in The ability to adhere to industry standards and regulations
HIIM certification is demonstrated through attaining credentials. Certified
The AHIMA Commission on Certification is nationally professionals are leaders in healthcare, displaying a
recognized as the most respected HIIM credentialing commitment to the industry, their colleagues, and
agency. AHIMA certifications provide validation of consumers.
professional competency to employers. Healthcare quality,
financial performance, and operational efficiency are Leverage the Benefits and Anticipate Results
strengthened by hiring AHIMA-credentialed professionals. Credentialed professionals offer employers a broad range
of benefits that can be leveraged for immediate application
to HIIM and other operations functions. Because they
Professional Certification through have pursued certification, credentialed professionals are
AHIMA ready to apply their skills and require less training than
Excellence in Operations and Healthcare Delivery noncredentialed peers. Their expertise reduces exposure
to fraud and abuse charges through precise, ethical
AHIMA establishes professional standards of excellence.
management of health information. The accuracy of health
Credentials are issued in HIIM, compliance and data
data is increased, making it more meaningful and positively
quality, coding, privacy and security, and health data
affecting the revenue cycle.
analysis, responding to the demands of the rapidly
changing healthcare environment. These key factors influence the success of healthcare
organizations through improved delivery of quality
Dedication Required, Competency Ensured healthcare and enhanced operational efficiency, producing
Credentials are earned through a combination of education, results that impact the bottom line.
experience, and performance on certification exams.
Following initial certification, credentials must be main-
tained through rigorous continuing education, ensuring the
highest level of competency for employers and consumers.

AHIMA CERTIFICATION CANDIDATE GUIDE Updated June 27, 2017 3


ABOUT CERTIFICATION
Certification is a means for showing that a certified Other benefits include:
professional possesses the knowledge and skills necessary • Credentialed professionals receive better compensation
for optimal performance of his or her job. Through from their employers
credentialing, the practitioner’s employer, peers, and the
• Employers know they’ve hired productive and
public are reassured the certified individual is both
knowledgeable individuals
competent and well-informed in the daily and accurate
administration of his or her professional duties. Certain • Certification marks a professional as an exceptional
professions (for example, doctors, lawyers, technicians, individual in his or her field
and others) require that the individuals performing their • Greater chance for advancement in one’s chosen career
duties be certified, owing to legal or safety reasons or high
• Certification gives greater insight on potential
professional standards. Whatever the reason, credentialing
employees during the hiring process
makes a professional a likelier candidate for gainful
employment and career advancement. • Consumers are protected from the threat of
incompetent or unfit practitioners
• A certified professional’s work reflects the best practices
and high professional standards of his or her field.

ABOUT AHIMA CREDENTIALS

Registered Health Information and pharmaceutical companies.


Administrator (RHIA) Eligibility Requirements
Working as a critical link between care providers, payers, and pa- RHIA applicants must meet one of the following eligibility
tients, the RHIA is an expert in managing patient health informa- requirements:
tion and medical records, administering computer information
systems, collecting and analyzing patient data, and using classifica- • Successfully complete the academic requirements, at the
tion systems and medical terminologies. Underlying this expertise baccalaureate level, of an HIM program accredited by
is a comprehensive knowledge of medical, administrative, ethical, the Commission on Accreditation of Health Informatics
and legal requirements and standards related to healthcare delivery and Information Management Education (CAHIIM)1
and the privacy of protected patient information. RHIAs often OR
manage people and operational units, participate in administrative • Successfully complete the academic requirements, at
committees, and prepare budgets. RHIAs interact with all levels of the master’s level, of an HIM program accredited by
an organization—clinical, financial, administrative, and informa- CAHIIM and following a specific set of criteria.
tion systems—that employ patient data in decision making and
everyday operations.
OR
Job opportunities for RHIAs exist in a multitude of • Graduate from an HIM program approved by a foreign as-
settings throughout the healthcare industry. These include sociation with which AHIMA has a reciprocity agreement2
the continuum of care delivery organizations, including OR
hospitals, multi-specialty clinics and physician practices, • Be an RHIT who meets the Proviso conditions
long-term care, mental health, and other ambulatory care approved by the 2017 Commission on Certification
settings. The profession has seen significant expansion for Health Informatics and Information Management
in non-patient care settings, with careers in managed (CCHIIM).³
care and insurance companies, software vendors,
The academic qualifications of each candidate will be
consulting services, government agencies, education,

1. Students in CAHIIM-accredited programs for RHIT or RHIA, enrolled 2. A


 HIMA and the Canadian Health Information Management Associa-
in their final term of study, are now eligible to apply for and take their tion (CHIMA); Korean Medical Record Association (KMRA); and
respective certification exam early. Eligible Health Information Management Association of Australia (HIMAA)
students include the following: shall permit a graduate of a program in HIM at the baccalaureate
• Students currently enrolled and in their last term of study degree level to apply to write the appropriate certification examination
consistent with the academic level achieved and given independently
• Students who have completed their coursework but have not yet by the aforementioned associations. The graduate must meet the edu-
graduated cational competencies for certification as a technician or administrator
• Graduates currently waiting for their official transcripts established by the association to which the application is made.

4 Updated June 27, 2017 AHIMA CERTIFICATION CANDIDATE GUIDE


verified before a candidate is deemed eligible to take the examination. All first-time applicants must submit an
examination. All first-time applicants must submit an official transcript from their college or university
official transcript from their college or university.1
Certified Coding
Registered Health Information Associate (CCA)
Technician (RHIT) The CCA credential distinguishes coders by exhibiting
Professionals holding the RHIT credential are health commitment and demonstrating coding competencies
information technicians who ensure the quality of across all settings, including both hospitals and
medical records by verifying their completeness, accuracy, physician practices. Becoming a CCA positions you as a
and proper entry into computer systems. They may also use leader in an exciting and growing market. CCAs also:
computer applications to assemble and analyze patient data • Exhibit a level of commitment, competency, and
for the purpose of improving patient care or controlling professional capability that attracts employers
costs. RHITs often specialize in coding diagnoses and
procedures in patient records for reimbursement and • Demonstrate a commitment to the coding profession
research. An additional role for RHITs is cancer • Distinguish themselves from noncredentialed coders
registrars—compiling and maintaining data on cancer and those holding credentials from organizations less
patients. With experience, the RHIT credential holds solid demanding of the higher level of expertise required to
potential for advancement to management positions, earn AHIMA certification
especially when combined with a bachelor’s degree. Based upon job analysis standards and state-of-the-art
Although most RHITs work in hospitals, they are also test construction, the CCA designation has been a
found in other healthcare settings including office-based nationally accepted standard of achievement since 2002.
physician practices, nursing homes, home health agencies, More than 8,000 people have attained the certification
mental health facilities, and public health agencies. In fact, since its inception. The CCA is the only HIIM credential
employment opportunities exist for RHITs in any worldwide currently accredited by the National
organization that uses patient data or health information, Commission for Certifying Agencies (NCCA).
such as pharmaceutical companies, law and insurance
firms, and health product vendors. Eligibility Requirements
• High school diploma or equivalent (no change)
Eligibility Requirements
Training and Recommendations—expanded
RHIT applicants must meet one of the following eligibility
recommendations (not required):
requirements:
• Six months coding experience directly applying codes;
• Successfully complete the academic requirements,
at an associate’s degree level, of an HIM program OR
accredited by the Commission on Accreditation of • Completion of an AHIMA-approved coding program
Health Informatics and Information Management (PCAP Program);
Education (CAHIIM)1&4 OR
OR • Completion of other coding training program to
• Graduate from an HIM program approved by a include anatomy and physiology, medical terminology,
foreign association with which AHIMA has a Basic ICD diagnostic/procedural and Basic CPT coding.
reciprocity agreement5
The academic qualifications of each candidate will be
verified before a candidate is deemed eligible to take the

3. Registered Health Information Technicians (RHIT) who meet the 4. Students interested in obtaining a Post-Baccalaureate Certificate, a Certifi-
following eligibility requirements will be eligible to sit for the RHIA cate of Completion, or Transfer of Credits information must contact the
examination during the timeframe of July 1, 2017 through 2021: CAHIIM-accredited program in which they wish to enroll regarding their
• Have at least a baccalaureate degree from a regionally accredited institutional policies. Please visit the program directory website at cahiim.
institution or nationally recognized accreditor; and org/accredpgms.asp to access the list of CAHIIM-accredited programs.

• Have received their RHIT credential on or before August 31, 2018; and 5. AHIMA and the Canadian Health Information Management Association
(CHIMA) shall permit a graduate of a program in HIM at the associate
• Have complied with the Standards for Maintenance of the RHIT credential. or baccalaureate degree level to apply to write the appropriate certifica-
tion examination consistent with the academic level achieved and given
independently by the two associations. The graduate must meet the edu-
cational competencies for certification as a technician or administrator
established by the association to which the application is made.

AHIMA CERTIFICATION CANDIDATE GUIDE Updated June 27, 2017 5


Certified Coding Certified Coding Specialist—
Specialist (CCS) Physician-based (CCS-P)
CCSs are professionals skilled in classifying medical data The CCS-P is a coding practitioner with expertise in
from patient records, generally in the hospital setting. physician-based settings such as physician offices, group
These coding practitioners review patients’ records and practices, multi-specialty clinics, and specialty centers. He
assign numeric codes for each diagnosis and procedure. or she reviews patients’ records and assigns numeric codes
To perform this task, they must possess expertise in the for each diagnosis and procedure. To perform this task, the
ICD-10-CM and CPT coding systems. In addition, the CCS individual must possess in-depth knowledge of the CPT
is knowledgeable in medical terminology, disease processes, coding system and familiarity with the ICD-10-CM and
and pharmacology. Hospitals and medical providers report HCPCS Level II coding systems. The CCS-P is also
an expert in health information documentation, data
coded data to insurance companies, or to the government
integrity, and quality. Because patients’ coded data is
in the case of Medicare and Medicaid recipients, for reim-
submitted to insurance companies or the government for
bursement of expenses.
expense reimbursement, the CCS-P plays a critical role in
Researchers and public health officials also use coded the health provider’s business operation. With the growth
medical data to monitor patterns and explore new of managed care and the movement of health services
interventions. Coding accuracy is thus highly important to delivery beyond the hospital, the employment outlook for
healthcare organizations because of its impact on revenues this coding specialty looks highly favorable. The CCS-P
and describing health outcomes, and in fact, certification certification exam assesses mastery-level proficiency in
is becoming an implicit industry standard. Accordingly, coding rather than entry-level skills. Professionals
the CCS credential demonstrates tested data quality and performing coding in a doctor’s office, clinic, or similar
integrity skills in a coding practitioner. The CCS setting should consider obtaining the CCS-P certification to
certification exam assesses mastery proficiency in coding attest to their capabilities.
rather than entry-level skills. Professionals experienced in
coding inpatient and outpatient records should consider
obtaining this certification.

CCS and CCS-P Eligibility Requirements


Candidates must meet one of the following eligibility requirements:
• By Credential: RHIA, RHIT, or CCS/CCS-P;
OR
• By Education: Completion of a coding training program that includes anatomy and physiology, pathophysiology,
pharmacology, medical terminology, reimbursement methodology, intermediate/advanced ICD
diagnostic/procedural and CPT coding;
OR
• By Experience: Minimum of two (2) years of related coding experience directly applying codes;
OR
• By Credential
with Experience: CCA plus one (1) year of coding experience directly applying codes;
OR
• Other: Coding credential from other certifying organization plus one (1) year coding experience directly
applying codes.

Certified Health Data Analyst (CHDA) Eligibility Requirements


Individuals who earn the CHDA designation will achieve recogni- Effective February 1, 2016, candidates must meet one of the
tion of their expertise in health data analysis and validation of their following eligibility requirements for the Certified Health
mastery of this domain. This prestigious certification provides Data Analyst examination:
practitioners with the knowledge to acquire, manage, analyze, • Healthcare information management credential (RHIT®) and
interpret, and transform data into accurate, consistent, and timely minimum of three (3) years of healthcare data experience
information, while balancing the “big picture” strategic vision with • Baccalaureate degree and a minimum of three (3) years
day-to-day details. CHDA-certified professionals will exhibit broad of healthcare data experience
organizational knowledge and the ability to communicate with in-
dividuals and groups at multiple levels, both internal and external. • Healthcare information management credential (RHIA®)
• Master’s in Health Information Management (HIM) or
Health Informatics from an accredited school

6 Updated June 27, 2017 AHIMA CERTIFICATION CANDIDATE GUIDE


• Master’s or higher degree and one (1) year of healthcare • Baccalaureate degree and a minimum of four (4) years
data experience experience in healthcare privacy or security management
All candidates who have applied to sit for the exam prior to • Healthcare information management credential
February 1, 2016 based on the previous eligibility require- (RHIA) and minimum of two (2) years of experience in
ments below will be able to proceed in sitting for the exam healthcare privacy or security management
• Associate’s degree and minimum of five (5) years of • Master’s or related degree (JD, MD, or PhD) and two
healthcare data experience (2) years of experience in healthcare privacy or security
• Healthcare information management credential (RHIT®) and management
minimum of three (3) years of healthcare data experience
• Baccalaureate degree and a minimum of three (3) years Certified Documentation
of healthcare data experience Improvement Practitioner (CDIP)
• Healthcare information management credential (RHIA®) The CDIP certification will confirm the commitment
and minimum of one (1) year of healthcare data experience of AHIMA to globally improve and maintain quality
• Master’s or related degree (JD, MD, or PhD) and one (1) information for those involved in healthcare and support
year of healthcare data experience the integrity of the patient’s health record.
AHIMA’s Commission on Certification reserves the right The certification will distinguish those professionals
to verify the information supplied by, or on behalf of, a serving as clinical documentation specialists as
candidate. If selected for an audit, the candidate may be asked knowledgeable and competent to provide guidance relative
to submit additional documentation supporting eligibility. to clinical documentation in the patient’s health record,
thus promoting the HIM profession overall.
Taking the certification examination is voluntary. AHIMA
strictly adheres to the eligibility requirements for certification. Eligibility Requirements
It is the responsibility of the candidate to comply with all • An RHIA, RHIT, CCS, CCS-P, RN, MD, or DO and two (2)
procedures and deadlines in order to establish eligibility for the years experience in clinical documentation improvement
examination. For questions about eligibility, please contact:
• An associate’s degree or higher and three (3) years
Attn: Certification Department of experience in clinical documentation improvement
AHIMA (candidates must also have completed coursework in
233 N. Michigan Ave., 21st Fl. Medical Terminology and Anatomy and Physiology)
Chicago, IL 60601
Telephone: (800) 335-5535
Web: ahima.org/contact Certified Healthcare Technology
Specialist (CHTS) Exams
Certified in Healthcare Privacy and As the nation moves toward industry-wide adoption of elec-
tronic health records (EHRs), the Bureau of Labor Statistics
Security (CHPS) expects a shortage of about 50,000 qualified health IT work-
The CHPS credential denotes competence in designing, ers to meet the needs of hospitals and healthcare affiliates.
implementing, and administering comprehensive privacy The Certified Healthcare Technology Specialist (CHTS)
and security protection programs in all types of healthcare competency exams allow professionals and employers to
organizations. Becoming certified in healthcare privacy capitalize on new technologies, procedures and careers.
and security demonstrates a choice to focus and advance by
The CHTS exams assess the competency of individuals
specializing in privacy and security dimensions of HIIM.
seeking to demonstrate proficiency in certain health IT
Being distinguished with this special expertise signifies workforce roles integral to the implementation and manage-
a commitment to advancing privacy and security ment of electronic health information. The CHTS exams
management practices and lifelong learning and assess the competency of health IT professionals to:
professional development.
• Assess workflows
Eligibility Requirements • Select hardware and software
CHPS applicants must meet one of the following eligibility • Work with vendors
requirements for the CHPS examination:
• Install and test systems
• Associate’s degree and six (6) years experience in
• Diagnose IT problems
healthcare privacy or security management
• Train practice staff on systems
• Healthcare information management credential (RHIT)
and minimum of four (4) years of experience in For additional information, please visit ahima.org/certifica-
healthcare data experience tion/chts

AHIMA CERTIFICATION CANDIDATE GUIDE Updated June 27, 2017 7


Certified Professional in prestigious premier professional association.
Health Informatics (CPHI) Eligibility Requirements1
With the continuing advancements in technology and the Candidates must meet one of the following eligibility
increasing demand for qualified health informatics profes- requirements for the Health Informatics examination
sionals the new informatics credential will provide credibil- • Baccalaureate degree and two (2) years of health
ity and recognition to individuals who possess the required informatics experience*
knowledge and expertise of health informatics. The new
• Master’s degree or higher and one (1) year of health
credential will enable an individual to further advance their
informatics experience*
career. It also demonstrates a competent workforce and
professional group for system support, subsequent organiza- • Master’s degree in health informatics from an accredited
tional support, prestige, and the opportunity to belong to a health informatics program

APPLYING FOR THE EXAM


Submitting an Application Incomplete Applications
Before submitting an application, carefully review the informa- An application may be considered incomplete for the
tion contained in this guide. It is the candidate’s responsibility to following reasons:
ensure eligibility before submitting the application. Applicants • Insufficient fee included, declined credit card, or
who are determined to be ineligible, and submit an ineligible returned check
application or request withdrawal of their application, will re-
ceive a refund of the application fee minus a $75 processing fee. • Application is not signed
Applicants may register online at ahima.org/certification or • Missing official transcript
by submitting a paper application, which can also be found • Missing Request for Accommodations form and
at ahima.org/certification. documentation form (if applicable)
When completing the application be sure to: Checks for insufficient funds (NSF) will not be
• Ensure the name on the application matches the name re-deposited. If the bank does not clear your check, a fee of
on the identification (ID) to be used for admission to the $25 will be incurred. Visa, MasterCard, American Express, or
test center (see section on Identification Requirements). Discover transactions declined or not approved will also be
• Indicate if an acknowledgment letter should be sent to subject to a $25 handling fee. A certified check or money order
your employer after certification is achieved. for the amount due, including the NSF fee, must be submitted
• Include the education program code (EPC) on the to AHIMA to cover returned checks or credit card transactions.
application (for RHIA, RHIT, and CCA applicants only). Postdated checks are not an acceptable form of payment.
• Submit verification of eligibility, if applicable. (Official Once an application is complete, the application will be processed
transcript for RHIA and RHIT only) and Pearson VUE will send an Authorization to Test (ATT) letter.
• Sign and date the application in ink (if using a paper
application). Independent Testing Agency
• Make copies for your records. Pearson VUE has been contracted by AHIMA to help
• Include the correct application fee by referring to the administer AHIMA’s certification examinations in the United
AHIMA website for current exam pricing. States and internationally. Pearson VUE delivers millions of high-
• Mail a paper application, using a traceable method, to: stakes tests every year across the globe for clients in the licensure,
Attn: Certification Examinations certification, academic admissions, regulatory, and government
AHIMA testing service markets. It boasts the world’s leading test center
Dept. 77-3081 network, with more than 5,000 test centers in 165 countries, 230
Chicago, IL 60678-3081 of which are fully owned and operated Pearson Professional
Centers. Pearson Professional Centers utilize a patent-winning
Nondiscrimination Policy design, which was created specifically for high-stakes testing and
AHIMA and Pearson VUE do not discriminate against offers a carefully controlled, consistent testing environment.
any candidate on the basis of race, color, creed, age, gender, For more information about Pearson VUE, please visit
national origin, religion, disability, marital status, parental status, pearsonvue.com/ahima.
ancestry, sexual orientation, military discharge status, or source
of income. All examination applicants will be judged solely on
the criteria established by the Commission on Certification.

1. Candidates are responsible for ensuring their eligibility to sit for the exam. Candidates must formally attest to the required experience in health informatics.

8 Updated June 27, 2017 AHIMA CERTIFICATION CANDIDATE GUIDE


TEST TAKERS’ RIGHTS AND RESPONSIBILITIES
As a test taker, you have the right to: • As a test taker, you have the responsibility to:
• Be informed of your rights and responsibilities as a test taker. • Read or listen to your rights and responsibilities as a test taker.
• Be treated with courtesy, respect, and impartiality, • Treat others with courtesy and respect during the
regardless of your age, disability, ethnicity, gender, testing process.
national origin, religion, sexual orientation, or other • Ask questions prior to testing if you are uncertain about
personal characteristics. why the test is being given, how it will be given, what you
• Be tested with measures that meet professional will be asked to do, and what will be done with the results.
standards and are appropriate, given the manner in • Read or listen to descriptive information in advance of
which the test results will be used. testing and listen carefully to all test instructions. You
• Receive a written explanation prior to testing about the should inform AHIMA before scheduling your test if
purpose(s) for testing, the kind(s) of tests to be used, if you wish to receive a testing accommodation, or if you
the results will be reported to you or to others, and the have a physical condition or illness that may interfere
planned use(s) of the results. If you have a disability, you with your performance on the test.
have the right to inquire and receive information about • Know when and where the test will be given, pay for the
testing accommodations. test if required, appear on time with any required mate-
• Know in advance of testing when the test will be rials (for example, valid identification and codebooks, if
administered, if and when test results will be available to allowed), and be ready to be tested.
you, and if you are expected to pay a fee for testing services. • Follow the test instructions you are given and represent
• Have your test administered and your test results yourself honestly during the testing.
interpreted by appropriately trained individuals who • Be familiar with and accept the consequences of not
follow a professional code of ethics. taking the test, should you choose not to take the test.
• Know the consequences of taking or not taking the test, • Inform appropriate person(s) (as specified to you by the
fully completing the test, or canceling the scores. You organization responsible for testing) if you believe that
may need to ask questions to learn these consequences. testing conditions affected your results.
• Receive a written explanation of your test results • Ask about the confidentiality of your test results, if this
within a reasonable amount of time after testing and aspect concerns you.
in commonly understood terms.
• Present concerns, if you have any, about the testing pro-
• Have your test results kept confidential to the extent cess or results immediately after the test.
allowed by law.
• Present concerns about the testing process or your
results, and receive information about procedures that Adopted from the American Psychological Association Test
will be used to address such concerns. Takers’ Rights and Responsibilities

AHIMA EXAM APPLICATION CHECKLIST


Candidates must ensure that all items on this checklist are completed in order for their exam to be processed:
❑❑ Read the Candidate Guide ❑❑ For Certificate of Degree candidates: Send in veri-
❑❑ Make sure the first and last name provided on fication letter from Program Director with exam
the application matches the name on the primary application
Identification ❑❑ For all other candidates: Send in official (sealed)
❑❑ Confirm meeting eligibility criteria transcripts separately to:
Paper:
❑❑ Include payment (credit card, check, money order)
Certification Transcripts
❑❑ Complete special accommodations form (American
233 N. Michigan Ave., 21st Fl.
with Disabilities Act), if applicable
Chicago, IL 60601
❑❑ Sign Statement of Understanding
OR
For RHIA and RHIT candidates only: Electronic (if this option is available, vendor infor-
❑❑ For Early Testing candidates: Include completed ap- mation is provided by your school:
plication for early testing with exam application CertificationTranscripts@ahima.org

AHIMA CERTIFICATION CANDIDATE GUIDE Updated June 27, 2017 9


SCHEDULING THE EXAMINATION
Authorization to Test (ATT) Letters For fast and easy scheduling, testing appointments may be
scheduled by logging in at pearsonvue.com/ahima. You may
After eligibility for the examination is approved, Pearson VUE
also call Pearson VUE’s customer service number at (888)
will send the candidate an Authorization to Test (ATT) letter
by e-mail for those candidates with a valid e-mail address (see 5AHIMA2 (524-4622) (wait time may vary depending on
Appendix B). Letters will be mailed to those candidates without candidate volume). When scheduling an exam, candidates
a valid e-mail address. Candidates with an approved applica- should be prepared to provide the authorization number
tion will receive the ATT letter within five (5) business days. located in the ATT letter. After the exam is scheduled,
The ATT letter contains an authorization number, the eligibility candidates will receive information about the time and
period for testing, and instructions for scheduling an appoint- date of the exam, and a confirmation number. Candidates
ment. Candidates may only schedule their appointment within should keep a copy of this information for future reference.
their four-month eligibility window. The eligibility start date Directions to the testing center may be obtained by logging
and end date are provided in the ATT letter. on to pearsonvue.com. ATT letters are not required at the
testing center.
Scheduling an Appointment to Test
The testing appointment should be scheduled soon after receiv- Test Centers
ing the ATT letter. Scheduling an appointment early in the eligi- Test centers are available throughout the United States and
bility period increases the likelihood that the candidate can sit for internationally. A complete listing of test center locations in the
the exam at his or her optimal date and time. Space at the Pearson US, including addresses and driving directions may be found
VUE testing centers is limited and the availability of a testing on Pearson VUE’s website: pearsonvue.com/ahima. Global test
“seat” is not guaranteed. Therefore, candidates who schedule their centers locations can be found by going to ahima.org/certifica-
exams in the latter part of their eligibility period run the risk of tion and click on the corresponding certification exam.
not sitting for the exam and forfeiting the exam fee. Before the day of the examination, please be sure the address
Before scheduling a testing appointment, be sure the name and directions to the test center are correct. If a candidate
on the eligibility letter is identical to the name on all forms of goes to the wrong test center on the day of the examination
identification being used. In the event of any errors or a name and cannot test, their exam fee will be forfeited and candidate
change, please contact Pearson VUE at (888) 524-4622. must re-apply and re-submit another application and fee.

APPOINTMENT CHANGES

Policy on Cancelling or Rescheduling Deadline Rescheduling Fee


AHIMA’s policies about changing a testing appointment are Up to 15 business days before No charge
as follows: exam date
• Candidates may cancel and reschedule the examination up to Between 14 business days and $30
15 days prior to the scheduled examination date at no charge. 24 hours prior to exam date
• Any candidate who reschedules or cancels his or her No-shows Forfeit application fee
appointment between 14 days and 24 hours prior to the
exam date will be charged a penalty of $30 by Pearson
VUE. Rescheduling and payment must be completed
Refund Policy
using a valid credit card through pearsonvue.com/ Candidates can request a refund for their exam application up
ahima or by calling the Pearson VUE Call Center at to fourteen (14) business days prior to their scheduled test date
(888) 524-4622. or eligibility end date.
• Candidates may not reschedule the examination less All appointments must be canceled through Pearson VUE
prior to the request for a refund.
than 24 hours prior to the examination appointment.
There is a $75 processing fee for all refund requests. Refunds
• Candidates who do not arrive or who arrive late to their
will be credited back to the card that was used for payment.
scheduled exam appointment time will be considered
If payment was made with a check; a check will be issued and
no-shows and will forfeit their application fee. sent to the mailing address on file.
• Candidates failing to appear for the scheduled Please allow two to four weeks for processing if paid with a
appointment or who are over 15 minutes late will not be credit card and up to six weeks if paid with a check.
allowed to test. A new application and the full
Refunds will not be granted if requested after eligibility end date.
application fee must be submitted in order to test.
10 Updated June 27, 2017 AHIMA CERTIFICATION CANDIDATE GUIDE
Penalties • Any candidate that arrives to the testing center 15 min-
utes late after his or her scheduled appointment will not
• Any candidate who reschedules or cancels his or her
be allowed to test and the exam fee will be forfeited.
appointment between 14 days and 24 hours prior to the
exam date will be charged a penalty of $30 by Pearson VUE. • Any candidate who has requested a refund but has not
canceled his or her schedule appointment before the end of
• Any candidate who does not bring the correct code
their eligibility end date will not be eligible for a refund.
books to the testing site will not be allowed to test and
the exam fee will be forfeited. • Any candidate who shows up to the wrong testing location
will not be allowed to test and the exam fee will be forfeited.
• Any candidate who does not bring the proper identifica-
tion to the testing site will not be allowed to test and the • Any candidate who forfeited his/her exam and is still
exam fee will be forfeited. seeking to test will have to submit a new exam application
along with payment.

ELIGIBILITY EXTENSION FEE AND POLICY


Candidates may request an extension for their eligibility Phone: (800) 335-5535
period by following the policy outlined below: Fax: (312) 233-1413
1. First Request for an Extension–$75
Note: Requests for an extension must be received no
(valid for 45 days)
later than 14 business days prior to the scheduled exam
2. Second and Final Request for an Extension–$150 date or eligibility end date.
(valid for an additional 30 days)
2. If you already scheduled your exam date with Pearson
Note: No additional extension will be authorized. VUE, you must contact Pearson VUE at (888) 524-4622
Steps for Requesting an Extension: directly and cancel your exam appointment prior to
requesting an extension.
1. Complete and submit the Eligibility Extension Request
Form (form available on ahima.org/certification) along 3. You will be notified via e-mail (e-mail address required
with the required fee by: on form) once your request has been processed and
approved.
Mail:
Attn: Certification Department/Extensions
AHIMA
233 N. Michigan Ave., 21st Fl.
Chicago, IL 60601

PREPARING FOR THE EXAM


Tips for Success • Know when and where the test will be given, appear on
time with any required materials (for example, valid
• Read through the entire candidate guide.
identification and codebooks if allowed), and be ready
• Visit AHIMA’s exam preparation page at to be tested.
ahima.org/certification. You will be able to:
• Please ensure that both forms of your identification
-- Review exam specifications meet the requirements posted on pearsonvue.com/
-- Review content outline ahima under “On Examination Day.”
-- Allow enough time to prepare for the exam.
“Cramming” is discouraged.

ON EXAMINATION DAY

Examination Procedures scheduled appointment. Candidates arriving at the test


center 15 minutes after the scheduled appointment will not
The Pearson VUE staff adheres to approved procedures to
be allowed to test and will forfeit the testing fee.
ensure the test center meets AHIMA’s testing criteria. Please
review the following information prior to the testing date to When arriving at the test center, candidates will:
ensure familiarity with the procedures. • Receive the Professional Examination Rules Agreement
Plan to arrive at the test center 30 minutes before the • Submit two valid, correct forms of identification (ID)
AHIMA CERTIFICATION CANDIDATE GUIDE Updated June 27, 2017 11
• Have their digital signature captured to verify that • Public aid card
signatures match • Temporary driver’s license without proper paperwork
• Have their palm vein pattern captured and photo identification
• Have a photograph taken • Temporary Social Security card without signature
• Store belongings • Video club membership card
• Show reference materials for approval (when applicable) • Traffic citation (arrest ticket)
• Fishing or hunting license
A dry erase board will be provided to all candidates for use
during the examination. No scratch paper is allowed. • AHIMA membership card
Without acceptable forms of ID, candidates will not be
Identification Requirements allowed to test and will forfeit the application fee. Pearson
To be allowed to test, candidates must present a primary VUE reserves the right to deny a candidate from taking
form of ID containing their signature and picture, and a the exam if there is a question in regards to the validity of
second form of ID showing their signature. The name on the ID(s).
the primary and secondary forms of ID must match the
To review the list of acceptable primary and secondary forms
name appearing on the ATT letter. of identification, please refer to pearsonvue.com/ahima.
Acceptable forms of primary ID must be valid and
nonexpired, and feature the candidate’s photograph and
Test Center Restrictions
signature. These include:
To ensure examination results for all candidates are earned under
• Government-issued driver’s licenses, including comparable conditions, it is necessary to maintain a standardized
temporary licenses with all required elements (refer to testing environment. Candidates must adhere to the following:
“Unacceptable forms of Candidate Identification” for an
exception when presented with a Texas driver’s license • For CCA, CCS, and CCS-P exams, candidates are required
that carries two expiration dates) to bring codebooks as indicated on the list of allowable
code books. (The list of allowable code for the CCA,
• US Dept of State driver’s license
CCS, and CCS-P are located on the AHIMA website).
• US learner’s permit (plastic card only with photo and
signature) • No reference or study materials may be brought into the
examination room.
• National/state/country identification card
• Code books with handmade tabs will not be allowed. Post-
• Passport
It Notes and/or any loose materials are also not allowed.
• Passport card Code books are for use on CCA, CCS, CCS-P exams only.
• Military ID • Documents or notes of any kind may not be removed
• Military ID for spouses and dependents from the examination room. All computer screens,
• Alien registration card paper, and written materials are the copyrighted
(green card, permanent resident visa) property of Pearson VUE and may not be reproduced
• Government-issued local language ID in any form.
(plastic card with photo and signature) • Candidates will not be allowed to take anything into the
examination room other than those items given to them
Acceptable forms of secondary ID must be valid and
by the administrator and their identification documents.
nonexpired, and feature the candidate’s signature.
These include: • Prohibited items will not be allowed in the examina-
tion room. Prohibited items include, but are not lim-
• Social Security card
ited to, the following: calculators, pagers, cell phones,
• Debit/ATM card electronic digital devices (PDAs, watches, and the
• Credit cards (must have a visible expiration date) like), recording or photographic devices, weapons,
• Any form of ID on the primary list briefcases, computers or computer bags, and hand-
bags or purses. Candidates cannot bring in drinks or
The following are examples of unacceptable forms of ID: snacks of any kind.
• Expired driver’s license or expired passport • Eating, drinking, and smoking are prohibited in the test
• Library card center.
• Marriage certificate • Questions regarding the content of the examination may
• Voter’s registration card not be asked of the test center administrator during the
• Club membership card examination.

12 Updated June 27, 2017 AHIMA CERTIFICATION CANDIDATE GUIDE


Security • Attempting to take the examination for someone else
All proprietary rights in the examinations, including • Using notes, books, or other aids
copyrights and trade secrets, are held by AHIMA. In order • Removing or attempting to remove note paper from the
to protect the integrity of the examinations and to ensure test center
the validity of the scores reported, candidates must adhere • Creating a disturbance or behaving in an abusive or
to strict guidelines regarding proper conduct in handling
otherwise uncooperative manner
copyrighted proprietary examinations. Any attempt to
reproduce all or part of the examinations, including, but not
limited to, removing materials from the examination room, Cancellation Due to Bad Weather or
aiding others by any means in reconstructing any portion of Other Emergencies
the examinations, selling, distributing, receiving or having In the event of bad weather, a natural disaster, or another
unauthorized possession of any portion of the examinations, emergency (for example, a test center power outage),
is strictly prohibited by law. Alleged copyright violations will Pearson VUE will determine whether circumstances
be investigated and, if warranted, prosecuted to the fullest warrant cancellation and rescheduling of examinations
extent of the law. It should be noted that all examination at a particular test center.
scores may be invalidated in the event of this type of
suspected breach. Examinations will not be cancelled and rescheduled if
the test center administrator can open the test center.
Candidates may not write on any examination materials Every attempt will be made to administer all
distributed by or belonging to AHIMA. examinations as scheduled.
A candidate can be disqualified from taking or continuing to sit However, should examinations at a test center be cancelled,
for an examination, or from receiving examination results, all affected candidates will be contacted by Pearson VUE
or the candidate’s scores might be cancelled, if Pearson VUE about rescheduling their examinations.
determines through proctor observation, statistical analysis,
and other evidence that the candidate’s score may not be
valid or that the candidate was engaged in collaborative,
Medical or Personal Emergency
disruptive, or other unacceptable behavior during the A medical or personal emergency is an unplanned event
administration of the examination. within three (3) days of the examination appointment
that prevents you from taking the exam will be taken into
Test centers are continuously monitored by audio and video consideration. A medical or personal emergency may apply
surveillance equipment for security purposes. to you or one of your immediate family member; spouse,
child, or parent as defined by the Family Medical Leave Act.
Misconduct Documentation (i.e. doctor’s note, emergency room forms,
Individuals who engage in the following conduct may be obituary) showing why you could not take your exam will be
dismissed from the test center and their scores will not required. Once all documentation is reviewed the candidate
be reported. Examples of misconduct include, but are not will be notified via e-mail with a decision. Please note,
limited to: without the submission of proper documentation, refunds
• Using electronic devices such as calculators, pagers, cell or extensions will not be granted and all exam fees will be
phones, and tablets forfeited. All documentation must be submitted no later than
• Giving or receiving help during the examination or 15 business days from the date of the exam appointment.
being suspected of doing so

AFTER THE EXAMINATION


Notification of Examination Results Newly credentialed professionals (if authorized) will
appear on AHIMA’s website at secure.ahima.org/
After completing the examination and evaluation,
candidates will be asked to report to the test center staff certification/newly_credentialed.aspx.
to receive their score report.
The score report will not include performance on pretest Confidentiality Procedures
questions, and these questions will not be used to AHIMA and Pearson VUE have adopted policies and
determine passing or failing. Candidates will receive their procedures to protect the confidentiality of examination
results immediately upon completion of their exam. candidates. AHIMA and Pearson VUE staff members will not
In the event a new exam format is introduced and the discuss pending examination applications with anyone but the
passing mark has not been pre-established, exam candidates candidate) and will not report scores by telephone, e-mail, or fax.
will receive a test completion notice upon completion of AHIMA and Pearson VUE will not release exam results to
their exam. Once the passing mark has been determined, educational institutions unless authorized by the candidate.
exam results will be sent to candidates via regular mail.
AHIMA CERTIFICATION CANDIDATE GUIDE Updated June 27, 2017 13
Validation of Scores ADA paperwork is also kept on file for three years from
the time of submission. Once the three years has passed a
AHIMA and Pearson VUE are responsible for the validity
new ADA application along with paperwork will have to be
and integrity of the scores reported. Occasionally, computer
resubmitted.
malfunctions or candidate misconduct may cause a score report
to be suspect. AHIMA and Pearson VUE reserve the right to void Candidates who are currently in their retest waiting period
or withhold examination results if, upon investigation, violation are not authorized to schedule until a new authorization to
of AHIMA’s regulations is discovered. Candidates are expected to test letter has been issued.
fully cooperate with any investigation. AHIMA is not authorized to waive retest periods due to test
security policies.
Release of Information For more information please visit ahima.org/certification.
All individuals who successfully complete an examination
may be recognized for this achievement on AHIMA’s website Use of the Credential
(authorization by the candidate is required.) AHIMA and
Candidates who pass the examination will be authorized to
Pearson VUE will not release scores to any other third party.
use RHIA, RHIT, CCA, CCS, CCS-P, CHDA, CHPS, CDIP, or
CHTS as applicable, following their name. AHIMA suggests
Certificates the following guidelines when using credentials:
Candidates who pass the examination will receive a • Academic degrees (for example, PhD, JD, and MBA) are
certificate specifying the credential has been awarded. listed closest to the last name.
AHIMA’s certificate vendor will send the official certificate • General credentials (for example, RHIA and RHIT) follow
within two (2) months of passing the examination. The the academic degree. If there is no academic degree listed,
candidate’s name will appear on the certificate exactly as it the certification credential follows the last name.
appears on the candidate’s AHIMA profile. • The RHIT credential will be superseded once a
Individuals seeking a replacement certificate because the origi- candidate passes the RHIA exam.
nal was lost, stolen, destroyed, or the name on the certificate has • Specialty credentials and coding credentials (for example,
changed, are required to complete the certificate replacement CHDA, CHP, CHS, CHPS, CCS, CCS-P, CCA, CDIP,
form. A form is available at ahima.org/certification/contact. and CHTS) follow the general credential.
If candidates do not receive their initial certificate, new • The CCA credential will be superseded once a candidate
certificates are free of charge only when requested within nine passes the CCS or CCS-P exam
months. Once nine months have passed since the certification • Fellowship credentials (for example, FAHIMA) follow
date, candidates must pay the $35 fee for the certificate. the specialty credential.
Candidates who apply for early testing and successfully pass • Early testing candidates are not authorized to use their
their exam will have their credential officially granted once credential until all requirements have been met and
transcripts are received and verified and will be subject to the verified through AHIMA.
recertification requirements as required by CCHIIM. The exam
date will be used as the official date the credential is granted. Registry
Once certified, candidates are added to the AHIMA
Examination Complaints registry. Certification status may be verified by employers,
Candidates are required to report any complaints at the test government agencies, and accrediting agencies. In addition,
center on the day of their examination. newly credentialed individuals are listed at: secure.ahima.
org/certification/newly_credentialed.aspx.
Because of the secure nature of the examination, neither
AHIMA nor Pearson VUE will disclose examination
questions or candidate’s responses to individual questions. Credential Verification
Certification status may be verified by employers,
Re-taking the Examination and Process government agencies, and accrediting agencies by
submitting a request by fax at (312) 233-1500, or e-mail at:
Candidates who have taken and failed an examination must credential_verification@ahima.org and are processed within
wait a minimum of 90 days before your application will be two to three business days. Requests must be submitted on
processed for the CDIP, CHDA, CHPS, and CCS-P, and 45 the company letterhead with the following information:
days for the CCA, CCS, CHTS, RHIA, and RHIT. To re-take
• Requestor’s name and title
an examination, a candidate must resubmit a new application
with the appropriate examination fee. Transcripts are kept on • Certified professional’s name
file and do not need to be resubmitted. • Credential
• Certified professional’s current residence (city and state)
14 Updated June 27, 2017 AHIMA CERTIFICATION CANDIDATE GUIDE
APPENDIX A
AHIMA Membership Application
qY
 es, please activate my AHIMA membership. By submitting my application I agree to abide by AHIMA’s Code of Ethics.
To review the Code of Ethics, visit ahima.org/ethics.

Last Name First Name Middle Initial Credential

Employer

Address q Home q Work

City State Zip Code Country

Home Phone

E-mail Address

Birthdate Last 4 digits of SSN

Membership Categories Payment Methods


Premier—Includes the highest level of AHIMA member benefits and
q Check/Money Order Make checks payable to AHIMA.
services. Premier members in good standing are entitled to all Premier
membership privileges including the right to vote. q Visa q MasterCard q American Express q Discover
New to AHIMA—This introductory membership type is available for up
to two years to any individual who has not previously been a member of
Card # Exp. Date
AHIMA.
Active Membership—For individuals interested in the AHIMA purpose
and willing to abide by the Code of Ethics. Active members in good Signature Date
standing shall be entitled to all membership privileges including the right
to vote. Component State Association (CSA)
Emeritus Membership—To apply for Emeritus membership please visit As a member residing in the United States, at least twenty percent
ahima.org/join. AHIMA members 65 and over are eligible for this (20%) of your membership dues are reimbursed to the CSA of your
member type. choice. A CSA will be assigned based on your address on this form.
Student Membership—To apply for student membership, please visit Please contact AHIMA if you wish to change your assigned CSA.
ahima.org/join. Some CSAs charge an additional assessment for membership.
Global/Outside US (oUS) Membership—To apply for Global/oUS There are 52 state associations, representing the 50 US states, the
membership, please visit ahima.org/join District of Columbia, and Puerto Rico. For details on how to contact
your state association, visit ahima.org/csa.
Membership Dues
Dues Information
q Premier (unlimited credentials).......................................................... $249
Dues are not refundable and membership is not transferable. A
q Premier (no credential)..........................................................................$199 portion of your dues is allocated to a Journal of AHIMA subscription:
q Active.........................................................................................................$185 $10 for student members and $22 for all others. The Journal subscrip-
For your first credential and $10 for each additional credential
tion rate is $100 per year. Members may not deduct the subscription
q Active (no credential).............................................................................$135 price from dues.
q New to AHIMA.......................................................................................$129 AHIMA dues are not deductible as a charitable contribution for
For your first credential and $10 for each additional credential
federal income tax purposes, but may be partially deductible as a
q New to AHIMA (no credential).............................................................$79 business expense. AHIMA estimates that 5% of your dues payment is
q Voluntary AHIMA Foundation Contribution....................................$10 not deductible because of AHIMA’s lobbying activities on behalf of
Total its members.

Membership dues prices are guaranteed through December 31, 2017. Remit to: AHIMA, Dept. 77-3081
Are you interested in group membership options? Please contact Chicago, IL 60678-3081, or
James Bell at (312) 233-1967.
Fax to: (312) 233-1500
AHIMA CERTIFICATION CANDIDATE GUIDE Updated June 27, 2017 15
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16 Updated June 27, 2017 AHIMA CERTIFICATION CANDIDATE GUIDE


APPENDIX B
Authorization to Test Letter

**PLEASE DO NOT RESPOND TO THIS E-MAIL**

Authorization to Test
You have been authorized to take a certification exam at a Pearson VUE testing center. Information on the
certification exam, the testing rules, and how to schedule your certification exam follows:

Authorized Candidate: John Doe

AHIMA Candidate ID: 1234567

Client Authorization ID: 891011 Pearson VUE Authorization ID: 223344556

Exam: CCS—Certified Coding Specialist

Number of Attempts Authorized: 1

Authorized Dates: 29 January 2013–29 May 2013

If any details of your authorization to test are incorrect, please contact AHIMA immediately at (800) 335-5535 or
Pearson VUE at (888) 524-4622 prior to scheduling your examination. Please note that the name on both your
primary and secondary forms of identification must exactly match your name as printed on this ATT letter.

ADA APPLICANTS
If you were approved for ADA accommodations you will receive a confirmation e-mail from AHIMA within 48 hours.
The confirmation email will provide the phone number you must use to schedule your AHIMA exam. ADA candidates
who do not schedule their exam through the proper channels will not receive their approved accommodations.

EXAMINATION DAY
You must be prepared to show two (2) valid, non-expired forms of personal identification. For more information on the
acceptable forms of identification, please visit www.pearsonvue.com/ahima. In addition, we ask that you arrive at the
testing center 30 minutes before your scheduled appointment time. This will provide adequate time to complete the
necessary sign-in procedures. If you arrive more than 15 minutes late for an examination you will be considered a no-
show and forfeit your exam fee.

CODE BOOK INFORMATION (FOR CCA, CCS, AND CCS-P EXAMS ONLY)
Please visit AHIMA's Certification website at www.ahima.org/certification prior to your testing date. Click "Exam
Name" for information for the exam that you are taking, then click “Exam Preparation” for the versions of the coding
books you're required to bring to the testing center for the exam.

RESCHEDULE AND CANCEL POLICY

If you wish to reschedule or cancel your exam appointment, you must do so at least one full business day (24 hours)
before the appointment via the Pearson VUE website or call center. Appointments must be rescheduled within the
authorized exam delivery period. All registrations with accommodations must be rescheduled or canceled through the
call center. If you cancel your exam appointment, you must also inform AHIMA and contact AHIMA regarding
refund policies. If you cancel or reschedule your appointment between 14 days and one full business day (24 hours)

AHIMA CERTIFICATION CANDIDATE GUIDE Updated June 27, 2017 17


APPENDIX B (continued)
Authorization to Test Letter

prior to your appointment time, you will be charged $30. If your request is made less than one full business day (24
hours) before your scheduled appointment time, or you fail to arrive for your appointment, you will be considered a
no-show and you will forfeit your exam fee.

REFUND POLICY
All refunds must be sent through AHIMA; Pearson VUE cannot process refunds for candidates. A cancellation of an
exam appointment does not constitute an exam refund. Please contact AHIMA at www.ahima.org/customersupport
for refunds.

To schedule this examination, follow the instructions below. Schedule early to obtain the date, time, and location of
your choice. Have your AHIMA candidate ID ready.

AFTER THE EXAM


After completing the examination and evaluation, candidates will be asked to report to the test center staff to receive
their score report or test completion notice. Candidates who pass the examination will receive a certificate specifying
that the credential has been awarded. The certificate will be mailed out within four (4) months of the examination.

INSTRUCTIONS FOR SCHEDULING YOUR APPOINTMENT

You may schedule the certification exam at a Pearson VUE testing center through the Pearson VUE Web site or by
calling the Pearson VUE Contact Center.

To schedule your certification exam on the Pearson VUE Website, go to this address:
http://www.pearsonvue.com/ahima
This Web site provides more information about certification exams, programs, and testing center locations.

To schedule your certification exam, first obtain a Pearson VUE Web account, username, and password. Follow
instructions on the Web site to create an account and register for the certification exam.

Once you set up your account, you can use it to review your exam information and also schedule, reschedule, and
cancel certification exams.

To schedule your certification exam or to get more information, you may contact the Pearson VUE Contact Center.
For a full listing of contact numbers please visit: http://www.pearsonvue.com/contact

You will be able to select a date and time within the authorized testing dates listed above, at a testing center of your
choice. Do not call the testing center directly. We encourage you to make an appointment soon, before all seats are
taken.

After scheduling the certification exam, you will be given instructions and sent a confirmation that includes
certification exam and appointment information, directions to the testing center, instructions on what to bring, and
other pertinent information.

www.pearsonvue.com

http://www.pearsonvue.com/legal/privacy/

18 Updated June 27, 2017 AHIMA CERTIFICATION CANDIDATE GUIDE


APPENDIX C
Sample Pass Score Report

AHIMA CERTIFICATION CANDIDATE GUIDE Updated June 27, 2017 19


APPENDIX C (continued)
Sample Fail Score Report

20 Updated June 27, 2017 AHIMA CERTIFICATION CANDIDATE GUIDE


APPENDIX D
Sample Test Completion Notice

AHIMA CERTIFICATION CANDIDATE GUIDE Updated June 27, 2017 21


APPENDIX E
Scale Scoring FAQs
1. What is a scaled score? 3. Does the use of scaled scoring change the number of
A scaled score is a conversion of a candidate’s raw score candidates who will pass the exam?
based on a scale of 100 to 400. The Commission on No. The change of scoring will not affect the rate of
Certification for Health Informatics and Information those who pass the exam. If a raw score would have
Management (CCHIIM) will administer the CCA, RHIA, passed or failed using the cold score reporting method,
and RHIT exams using multiple test forms. As such, each it will pass or fail using the scaled scoring method.
test form may have a different passing score to ensure the
difficulty level of each form is the same. To simplify the 4. What information will appear on my score report?
process of reporting scores, the CCA, RHIA, and RHIT • Your score report will identify the passing score, your
exam will be calibrated on a scale of 100 to 400, and will score, and the results.
have a passing score of 300. • Content categories will be listed by domain
Scaled scoring is a commonly used method for reporting along with the percentage of correct answers in
test scores among major allied health professional each domain.
organizations and is the currently adopted scoring • If a candidate passes, the following information is
method for the SAT and GMAT. provided on the web:
2. How can I interpret my score? -- Certificate information
Candidate’s scores are converted to scaled scores so that -- Recertification information
a particular score corresponds to the same level of -- Membership information
achievement regardless of the form the examination takes. -- Exam scoring information
In other words, a score of 300 on a specific examination • If a candidate fails, he or she will receive informa-
has the same meaning as a score of 300 on any form of tion on reapplying for the exam and exam scoring
the examination. This means the candidate will not be information.
penalized if the form of the examination taken is harder
than one given to another candidate.
Each domain of the exam is weighted differently, as shown
on the content outline available on the Certification
exams website and therefore cannot be average for a score.
Additionally, although it would appear that the passing
score of 300/400 equates to 75%, the passing score is
actually 300/400 based on our confidential scoring scale.

22 Updated June 27, 2017 AHIMA CERTIFICATION CANDIDATE GUIDE


APPENDIX F
AHIMA Accommodations under the Americans with Disabilities Act (ADA)
Policies and Procedures
How to Request Test Accommodations for the What to Do:
Certification Examinations • Read the AHIMA Disability Documentation Guidelines
• The applicant must personally submit a written carefully and share them with the qualified professional
request. who will be providing supporting documentation for
• Requests by a third party (such as an evaluator, your request.
employer, etc.) will not be considered. • Complete the AHIMA Test Accommodation Request
• If an applicant has a documented disability covered form
under the Americans with Disabilities Act (ADA) and • Attach documentation of the disability and your need
ADA Amendments Act (ADAAA) and requires test for accommodation.
accommodations, he or she must notify AHIMA in • Incomplete documentation will delay processing of
writing each time he or she requests accommodations. your request and exam application.
• The request should indicate the nature of the disability
and the specific test accommodations needed.
• A qualified professional must provide documentation
verifying the disability and explaining the test
accommodations that are needed.
• Applicants will be notified in writing whether their
accommodation request has been approved.

AHIMA CERTIFICATION CANDIDATE GUIDE Updated June 27, 2017 23


APPENDIX G
Registered Health Information Administrator (RHIA) Examination
Content Outline
Number of Questions on Exam: B. Data Privacy, Confidentiality, and Security
• 180 multiple choice (160 scored/20 pretest) B1. Design policies and implement privacy practices to
Exam Time: 4 hours—Any breaks taken will count safeguard Protected Health Information
against your exam time B2. Design policies and implement security practices to
safeguard Protected Health Information
DOMAIN 1 B3. Investigate and resolve healthcare privacy and
Data Content, Structure & Standards security issues/breaches
(Information Governance) (18–22%) C. Release of Information
Tasks: C1. Manage access, disclosure, and use of Protected
A. Classification Systems Health Information to ensure confidentiality
A1. Code diagnosis and procedures according to C2. Develop policies and procedures for uses and
established guidelines disclosures/redisclosures of Protected Health
Information
B. Health Record Content & Documentation
B1. Ensure accuracy and integrity of health data and
health record documentation (paper or electronic) DOMAIN 3
Informatics, Analytics & Data Use (22–26%)
B2. Manage the contents of the legal health record
(structured and unstructured) Tasks:
B3. Manage the retention and destruction of the legal A. Health Information Technologies
health record A1. Implement and manage use of, and access to,
C. Data Governance technology applications
C1. Maintain data in accordance with regulatory A2. Evaluate and recommend clinical, administrative,
requirements and specialty service applications (e.g., financial
systems, electronic record, clinical coding)
C2. Develop and maintain organizational policies,
procedures, and guidelines for management of B. Information Management Strategic Planning
health information B1. Present data for organizational use (e.g.,
D. Data Management & Secondary Data Sources summarize, synthesize, and condense information)
D1. Manage health data elements and/or data sets C. Analytics & Decision Support
D2. Assist in the maintenance of the data dictionary C1. Filter and/or interpret information for the end
and data models for database design customer
D3. Manage and maintain databases (e.g., data C2. Analyze and present information to organizational
migration, updates) stakeholders
C3. Use data mining techniques to query and report
DOMAIN 2 from databases
Information Protection: Access, Disclosure, D. Healthcare Statistics
Archival, Privacy & Security (23–27%) D1. Calculate healthcare statistics for organizational
Tasks: stakeholders
A. Health Law D2. Critically analyze and interpret healthcare statistics
A1. Maintain healthcare privacy and security training for organizational stakeholders (e.g., CMI)
programs E. Research Methods
A2. Enforce and monitor organizational compliance E1. Identify appropriate data sources for research
with healthcare information laws, regulations and F. Consumer Informatics
standards (e.g., audit, report and/or inform)

24 Updated June 27, 2017 AHIMA CERTIFICATION CANDIDATE GUIDE


APPENDIX G (continued)
Registered Health Information Administrator (RHIA) Examination
Content Outline
F1. Identify and/or respond to the information needs of E1. Query physicians for appropriate documentation to
internal and external healthcare customers support reimbursement
F2. Provide support for end-user portals and personal E2. Educate and train clinical staff regarding
health records supporting documentation requirements
G. Health Information Exchange
G1. Apply data and functional standards to achieve DOMAIN 5
interoperability of healthcare information systems Leadership (12–16%)
G2. Manage the health information exchange process Tasks:
entity-wide A. Leadership Roles
H. Information Integrity and Data Quality A1. Develop, motivate, and support work teams and/or
H1. Apply data/record storage principles and individuals (e.g., coaching, mentoring)
techniques associated with the medium (e.g., A2. Organize and facilitate meetings
paper-based, hybrid, electronic)
A3. Advocate for department, organization and/or
H2. Manage master person index (e.g., patient profession
record integration, customer/client relationship
B. Change Management
management)
B1. Participate in the implementation of new processes
H3. Manage merge process for duplicates and other
(e.g., systems, EHR, CAC)
errors entity-wide (e.g., validate data sources)
B2. Support changes in the organization (e.g., culture
changes, HIM consolidations, outsourcing)
DOMAIN 4
Revenue Management (12–16%) C. Work Design & Process Improvement
C1. Establish and monitor productivity standards
Tasks:
C2. Analyze and design workflow processes
A. Revenue Cycle & Reimbursement
C3. Participate in the development and monitoring of
A1. Manage the use of clinical data required in
process improvement plans
reimbursement systems and prospective payment
systems (PPS) D. Human Resources Management
A2. Optimize reimbursement through management of D1. Perform human resource management activities
the revenue cycle (e.g., chargemaster maintenance, (e.g., recruiting staff, creating job descriptions,
DNFB, and AR days) resolving personnel issues)
B. Regulatory E. Training & Development
B1. Prepare for accreditation and licensing processes E1. Conduct training and educational activities (e.g.
(e.g. Joint Commission, Det Norske Veritas (DNV), HIM systems, coding, medical and institutional
Medicare, state regulators) terminology, documentation and regulatory
requirements)
B2. Process audit requests (e.g., RACs or other payors,
chart review) F. Strategic & Organizational Management
B3. Perform audits (e.g., chart review, POC) F1. Monitor industry trends and organizational needs
to anticipate changes
C. Coding
F2. Determine resource needs by performing analyses
C1. Manage and/or validate coding accuracy
(e.g., cost benefit, business planning)
D. Fraud Surveillance
F3. Assist with preparation of capital budget
D1. Participate in investigating incidences of medical
G. Financial Management
identity theft
G1. Assist in preparation and management of operating
E. Clinical Documentation Improvement
and personnel budgets

AHIMA CERTIFICATION CANDIDATE GUIDE Updated June 27, 2017 25


APPENDIX G (continued)
Registered Health Information Administrator (RHIA) Examination
Content Outline
G2. Assist in the analysis and reporting on budget
variances
H. Ethics
H1. Adhere to the AHIMA code of ethics
I. Project Management
I1. Utilize appropriate project management
methodologies
J. Vendor/Contract Management
J1. Evaluate and manage contracts (e.g., vendor,
contract personnel, maintenance)
K. Enterprise Information Management
K1. Develop and support strategic and operational
plans for entity-wide health information
management

26 Updated June 27, 2017 AHIMA CERTIFICATION CANDIDATE GUIDE


APPENDIX H
Registered Health Information Technician (RHIT) Examination Content Outline

Number of Questions on Exam: DOMAIN 2


• 150 multiple-choice questions (130 scored/20 pretest) Coding (16–20%)
Exam Time: 3.5 hours—Any breaks taken will count Tasks:
against your exam time 1. Apply all official current coding guidelines
2. Assign diagnostic and procedure codes based on
DOMAIN 1 health record documentation
Data Analysis and Management (18–22%)
3. Ensure physician documentation supports coding
Tasks: 4. Validate code assignment
1. Abstract information found in health records (i.e.,
5. Abstract data from health record
coding, research, physician deficiencies, etc.)
6. Sequence codes
2. Analyze data (i.e., productivity reports, quality mea-
sures, health record documentation, case mix index, 7. Query physician when additional clinical
documentation is needed
3. M
 aintain filing and retrieval systems for health
records 8. Review and resolve coding edits (i.e. correct coding
initiative, outpatient code editor, NCD, LCD, etc.)
4. Identify anomalies in data
9. Review the accuracy of abstracted data
5. Resolve risks and/or anomalies of data findings
10. Assign POA (present on admission) indicators
6. M
 aintain the master patient index (i.e., enterprise
systems, merge/unmerge medical record numbers, etc.) 11. Provide educational updates to coders
7. Eliminate duplicate documentation 12. Validate grouper assignment (i.e. MS-DRG, APC, etc.)
8. Organize data into a useable format 13. Identify HAC (hospital acquired condition)
9. Review trends in data 14. Develop and manage a query process
10. Gather/compile data from multiple sources 15. Create standards for coding productivity and quality
11. Generate reports or spreadsheets (i.e., customize, 16. Develop educational guidelines for provider
create, etc.) documentation
12. Present data findings (i.e., study results, delinquencies, 17. Perform concurrent audits
conclusion/summaries, gap analysis, graphical
13. Implement workload distribution DOMAIN 3
14. Design workload distribution
Compliance (14–18%)
15. Participate
 in the data management plan (i.e., Tasks:
determine data elements, assemble components, 1. Ensure patient record documentation meets state and
set time-frame) federal regulations
16. Input and/or submit data to registries 2. Ensure compliance with privacy and security guide-
17. Summarize findings from data research/analysis lines (HIPAA, state, hospital, etc.)
18. Follow data archive and backup policies 3. Control access to health information
19. Develop data management plan 4. Monitor documentation for completeness
20. Calculate healthcare statistics (i.e., occupancy rates, 5. Develop a coding compliance plan (i.e., current coding
length of stay, delinquency rates, etc) guidelines)
21. Determine validation process for data mapping 6. Manage release of information
22. Maintain data dictionaries 7. Perform continual updates to policies and procedures
8. Implement internal and external audit guidelines
9. Evaluate medical necessity (CDMP—clinical
documentation management program)

AHIMA CERTIFICATION CANDIDATE GUIDE Updated June 27, 2017 27


APPENDIX H (continued)
Registered Health Information Technician (RHIT) Examination Content Outline

10. Collaborate with staff to prepare the organization for DOMAIN 5


accreditation, licensing, and/or certification surveys Quality (10–14%)
11. Evaluate medical necessity (Outpatient services) Tasks:
12. Evaluate medical necessity (Data management) 1. Audit health records for content, completeness,
13. Responding to fraud and abuse accuracy, and timeliness
14. Evaluate medical necessity (ISSI (utilization review)) 2. Apply standards, guidelines, and/or regulations to
15. Develop forms (i.e., chart review, documentation, health records
EMR, etc.) 3. I mplement corrective actions as determined by audit
16. Evaluate medical necessity (Case management) findings (internal and external)
17. Analyze access audit trails 4. Design efficient workflow processes
18. Ensure valid healthcare provider credentials 5. Comply with national patient safety goals
6. Analyze standards, guidelines, and/or regulations to
DOMAIN 4 build criteria for audits
Information Technology (10-14%) 7. Apply process improvement techniques

Tasks: 8. Provide consultation to internal and external users of


health information on HIM subject matter
1. Train users on software
9. Develop reports on audit findings
2. Maintain database
10. Perform data collection for quality reporting (core
3. Set up secure access measures, PQRI, medical necessity, etc.)
4. Evaluate the functionality of applications 11. Use trended data to participate in performance im-
5. Create user accounts provement plans/initiatives
6. Trouble-shoot HIM software or support systems 12. Develop a tool for collecting statistically valid data
7. Create database 13. Conduct clinical pertinence reviews
8. Perform end user audits 14. Monitor physician credentials to practice in the facility
9. Participate in vendor selection
10. Perform end user needs analysis
11. Design data archive and backup policies
12. Perform system maintenance of software and systems
13. Create data dictionaries

28 Updated June 27, 2017 AHIMA CERTIFICATION CANDIDATE GUIDE


APPENDIX H (continued)
Registered Health Information Technician (RHIT) Examination Content Outline

DOMAIN 6 DOMAIN 7
Legal (9–13%) Revenue Cycle (9–13%)
Tasks: Tasks:
1. Ensure confidentiality of the health records (paper 1. Communicate with providers to discuss documenta-
and electronic) tion deficiencies (i.e., queries)
2. Adhere to disclosure standards and regulations 2. Participate in clinical documentation improvement
(HIPAA privacy, HITECH Act, breach notifications, programs to ensure proper documentation of health
etc.) at both state and federal levels records
3. Demonstrate and promote legal and ethical standards 3. Collaborate with other departments on monitoring
of practice accounts receivable (i.e., unbilled, uncoded)
4. Maintain integrity of legal health record according to 4. Provide ongoing education to healthcare providers
organizational bylaws, rules and regulations (i.e., regulatory changes, new guidelines, payment
5. Follow state mandated and/or organizational record standards, best practices, etc)
retention and destruction policies 5. Identify fraud and abuse
6. Serve as the custodian of the health records (paper or 6. Assist with appeal letters in response to claim denials
electronic) 7. Monitor claim denials/over-payments to identify
7. Respond to Release of Information (ROI) requests potential revenue impact
from internal and external requestors 8. Prioritize the work according to accounts receivable,
8. Work with risk management department to provide patient type, etc.
requested documentation 9. Distribute the work according to accounts receivable,
9. Identify potential health record related risk manage- patient type, etc.
ment issues through auditing 10. Maintain the chargemaster
10. Respond to and process patient amendment requests 11. Ensure physicians are credentialed with different
to the health record payers for reimbursement
11. Facilitate basic education regarding the use of
consents, healthcare Power of Attorney, Advanced
Directives, DNRs, etc.
12. Represent the facility in court related matters as it
applies to the health record (subpoenas, depositions,
court orders, warrants)

AHIMA CERTIFICATION CANDIDATE GUIDE Updated June 27, 2017 29


APPENDIX I
Certified Coding Associate (CCA) Examination Content Outline

Number of questions on exam: DOMAIN 3


• 100 multiple-choice questions (90 scored/10 pretest) Health Records and Data Content (13–17%)
Exam Time: 2 hours—Any breaks taken will count Tasks:
against your exam time 1. Retrieve medical records
DOMAIN 1 2. Assemble medical records according to healthcare
Clinical Classification Systems (30–34%) setting
Tasks: 3. Analyze medical records quantitatively for complete-
ness
1. Interpret healthcare data for code assignment
4. Analyze medical records qualitatively for deficiencies
2. Incorporate clinical vocabularies and terminologies
used in health information systems 5. Perform data abstraction
3. Abstract pertinent information from medical records 6. Request patient-specific documentation from other
sources (ancillary depts., physician’s office, etc)
4. Consult reference materials to facilitate code assignment
7. Retrieve patient information from master patient
5. Apply inpatient coding guidelines
index
6. Apply outpatient coding guidelines
8. Educate providers in regards to health data standards
7. Apply physician coding guidelines
9. Generate reports for data analysis
8. Assign inpatient codes
9. Assign outpatient codes DOMAIN 4
10. Assign physician codes Compliance (12–16%)
11. Sequence codes according to healthcare setting Tasks:
1. Identify discrepancies between coded data and
DOMAIN 2 supporting documentation
Reimbursement Methodologies (21–25%) 2. Validate that codes assigned by provider or electronic
Tasks: systems are supported by proper documentation
1. Sequence codes for optimal reimbursement 3. Perform ethical coding
2. Link diagnoses and CPT codes according to payer 4. Clarify documentation through physician query
specific guidelines 5. Research latest coding changes
3. Assign correct DRG 6. Implement latest coding changes
4. Assign correct APC 7. Update fee/charge ticket based on latest coding
5. Evaluate NCCI edits changes
6. Reconcile NCCI edits 8. Educate providers on compliant coding
7. Validate medical necessity using LCD and NCD 9. Assist in preparing the organization for external
8. Submit claim forms audits
9. Communicate with financial departments
10. Evaluate claim denials
11. Respond to claim denials
12. Resubmit denied claim to the payer source
13. Communicate with the physician to clarify
documentation

30 Updated June 27, 2017 AHIMA CERTIFICATION CANDIDATE GUIDE


APPENDIX I (continued)
Certified Coding Associate (CCA) Examination Content Outline

DOMAIN 5
Information Technologies (6–10%)
Tasks:
1. Navigate throughout the EHR
2. Utilize encoding and grouping software
3. Utilize practice management and HIM systems
4. Utilize CAC software that automatically assigns codes
based on electronic text
5. Validate the codes assigned by CAC software

DOMAIN 6
Confidentiality & Privacy (6–10%)
Tasks:
1. Ensure patient confidentiality
2. Educate healthcare staff on privacy and confidentiality
issues
3. Recognize and report privacy issues/violations
4. Maintain a secure work environment
5. Utilize pass codes
6. Access only minimal necessary documents/
information
7. Release patient-specific data to authorized individuals
8. Protect electronic documents through encryption
9. Transfer electronic documents through secure sites
10. Retain confidential records appropriately
11. Destroy confidential records appropriately

AHIMA CERTIFICATION CANDIDATE GUIDE Updated June 27, 2017 31


APPENDIX J
Certified Coding Specialist (CCS) Examination Content Outline
Number of Questions on exam: Procedure:
• 97 multiple-choice questions (79 scored/18 pretest) 1. Select the procedures that require coding according to
• 8 medical scenarios (6 scored/2 pretest) current coding and reporting requirements for acute
care (inpatient) services
Exam Time: 4 hours—Any breaks taken will count
against your exam time 2. Select the procedures that require coding according
to current coding and reporting requirements for
outpatient services
DOMAIN 1
Health Information Documentation (8–10%) 3. Interpret conventions, formats, instructional
notations, and definitions of the classification system
Tasks: and/or nomenclature to select procedures/services that
1. Interpret health record documentation using require coding
knowledge of anatomy, physiology, clinical indicators 4. Sequence procedures according to notations and con-
and disease processes, pharmacology and medical ventions of the classification system/nomenclature and
terminology to identify codeable diagnoses and/or standard data set definitions (such as UHDDS)
procedures
5. Apply the official ICD-10 procedure coding guidelines
2. Determine when additional clinical documentation is
6. Apply the official CPT/HCPCS Level II coding
needed to assign the diagnosis and/or procedure code(s)
guidelines
3. Consult with physicians and other healthcare provid-
ers to obtain further clinical documentation to assist
with code assignment DOMAIN 3
Regulatory Guidelines and Reporting
4. Compose a compliant physician query Requirements for Acute Care (Inpatient)
5. C
 onsult reference materials to facilitate code Service (6–8%)
assignment
Tasks:
6. Identify patient encounter type
1. Select the principal diagnosis, principal procedure,
7. Identify and post charges for healthcare services based complications, comorbid conditions, other diagnoses
on documentation and procedures that require coding according to
UHDDS definitions and Coding Clinic
DOMAIN 2 2. Assign the present on admission (POA) indicators
Diagnosis & Procedure Coding (64–68%)
3. Evaluate the impact of code selection on Diagnosis
Tasks: Related Group (DRG) assignment

Diagnosis: 4. Verify DRG assignment based on Inpatient Prospec-


tive Payment System (IPPS) definitions
1. Select the diagnoses that require coding according to
current coding and reporting requirements for acute 5. Assign and/or validate the discharge disposition
care (inpatient) services
2. Select the diagnoses that require coding according to
current coding and reporting requirements for outpa-
tient services
3. Interpret conventions, formats, instructional
notations, tables, and definitions of the classification
system to select diagnoses, conditions, problems, or
other reasons for the encounter that require coding
4. Sequence diagnoses and other reasons for encounter
according to notations and conventions of the classifi-
cation system and standard data set definitions (such
as Uniform Hospital Discharge Data Set [UHDDS])
5. Apply the official ICD-10-CM/PCS coding guidelines

32 Updated June 27, 2017 AHIMA CERTIFICATION CANDIDATE GUIDE


APPENDIX J (continued)
Certified Coding Specialist (CCS) Examination Content Outline
DOMAIN 4 DOMAIN 6
Regulatory Guidelines and Reporting Information and Communication Technologies
Requirements for Outpatient Services (6–8%) (1–3%)
Tasks: Tasks:
1. Select the reason for encounter, pertinent secondary 1. Use computer to ensure data collection, storage,
conditions, primary procedure, and other procedures analysis, and reporting of information.
that require coding according to UHDDS definitions, 2. Use common software applications (for example, word
CPT Assistant, Coding Clinic, and HCPCS processing, spreadsheets, and e-mail) in the execution
2. Apply Outpatient Prospective Payment System (OPPS) of work processes
reporting requirements: 3. Use specialized software in the completion of
a. Modifiers HIM processes
b. CPT/HCPCS Level II
c. Medical necessity DOMAIN 7
d. Evaluation and Management code assignment Privacy, Confidentiality, Legal, and Ethical
(facility reporting) Issues (2–4%)
3. Apply clinical laboratory service requirements Tasks:
1. Apply policies and procedures for access and
DOMAIN 5 disclosure of personal health information
Data Quality and Management (2–4%) 2. Apply AHIMA Code of Ethics/Standards of
Ethical Coding
Tasks:
1. Assess the quality of coded data 3. Recognize and report privacy and/or security
concerns
2. Communicate with healthcare providers regarding
reimbursement methodologies, documentation rules, 4. Protect data integrity and validity using software or
and regulations related to coding hardware technology
3. Analyze health record documentation for quality and
completeness of coding DOMAIN 8
Compliance (2–4%)
4. Review the accuracy of abstracted data elements for
database integrity and claims processing Tasks:
5. Review and resolve coding edits such as Correct 1. Evaluate the accuracy and completeness of the patient
Coding Initiative (CCI), Medicare Code Editor (MCE) record as defined by organizational policy and exter-
and Outpatient Code Editor (OCE) nal regulations and standards
2. Monitor compliance with organization-wide health
record documentation and coding guidelines
3. Recognize and report compliance concerns

AHIMA CERTIFICATION CANDIDATE GUIDE Updated June 27, 2017 33


APPENDIX K
Certified Coding Specialist—Physician-Based (CCS-P) Examination Content Outline
Number of Questions on Exam: Procedure:
• 97 multiple-choice questions (79 scored/18 pretest) 1. Interpret conventions, formats, instructional
• 8 medical scenarios (6 scored/2 pretest) notations, and definitions of the classification system
Exam Time: 4 hours—Any breaks taken will count and/or nomenclature to select procedures/services that
against your exam time require coding
2. Select the procedures that require coding according
DOMAIN 1 to current reporting requirements for professional
Health Information Documentation (8–12%) services in any setting
3. Sequence procedures according to notations and
Tasks: conventions of the classification system/nomenclature
1. Interpret health record documentation using and standard data set definitions
knowledge of anatomy, physiology, clinical indicators
4. Apply the official CPT/HCPCS Level II coding
and disease processes, pharmacology and medical
guidelines
terminology to identify codeable diagnoses and/or
procedures
DOMAIN 3
2. Determine when additional clinical documentation
Regulatory Guidelines and Reporting
is needed to assign the diagnosis and/or procedure
Requirements for Outpatient Services (8–12%)
code(s)
3. Consult with physicians and other healthcare provid- Tasks:
ers to obtain further clinical documentation to assist 1. Select the reason for encounter, pertinent secondary
with code assignment conditions, primary procedure, and other procedures
4. C
 onsult reference materials to facilitate code that require coding according to CPT Assistant,
assignment Coding Clinic, and HCPCS
5. Identify patient encounter type 2. Apply appropriate reporting requirements:
6. Identify and post charges for healthcare services based a. Modifiers
on documentation b. CPT/ HCPCS Level II
c. Evaluation and Management code assignment
DOMAIN 2 3. Validate medical necessity for appropriate
Diagnosis and/or Procedure Coding (60–64%) relationships between diagnosis and coded
procedures/services
Tasks:
Diagnosis: DOMAIN 4
1. Interpret conventions, formats, instructional Data Quality and Management (5–7%)
notations, tables, and definitions of the classification
system to select diagnoses, conditions, problems, or Tasks:
other reasons for the encounter that require coding 1. Review the results of aggregate coded data as required
2. Select the diagnoses that require coding according 2. Communicate with healthcare providers regarding
to current coding and reporting requirements for reimbursement methodologies, documentation rules,
outpatient services and regulations related to coding
3. Sequence diagnoses and other reasons for encounter 3. Analyze health record documentation for quality and
according to notations and conventions of the classifi- completeness of coding
cation system and standard data set definitions 4. Review the accuracy of abstracted data elements for
4. Apply the official ICD-10-CM coding guidelines database integrity and claims processing
5. Resolve coding edits such as National Correct Coding
Initiative (NCCI)

34 Updated June 27, 2017 AHIMA CERTIFICATION CANDIDATE GUIDE


APPENDIX K (continued)
Certified Coding Specialist—Physician-Based (CCS-P) Examination Content Outline
DOMAIN 5
Information and Communication Technologies
(2–4%)
Tasks:
1. Use computer and mobile devices (tablet, hand-held,
etc.) to ensure data collection, storage, analysis, and
reporting of information
2. Use common software and web-based applications in
the execution of work processes
3. Use specialized software in the completion of HIM
processes

DOMAIN 6
Privacy, Confidentiality, Legal, and Ethical
Issues (4–6%)
Tasks:
1. Apply policies and procedures for access and
disclosure of protected health information
2. Apply AHIMA Code of Ethics/Standards of Ethical
Coding
3. Report privacy and/or security concerns
4. Protect data integrity and validity using software or
hardware technology

DOMAIN 7
Compliance (3–5%)
Tasks:
1. Evaluate the accuracy and completeness of the
patient record as defined by organizational policy and
external regulations and standards
2. Monitor compliance with organization-wide coding
guidelines
3. Report compliance concerns

AHIMA CERTIFICATION CANDIDATE GUIDE Updated June 27, 2017 35


APPENDIX L
Certified Health Data Analyst (CHDA) Examination Content Outline
Number of Questions on Exam: DOMAIN 3
• 150 multiple-choice (130 scored/20 pretest) Data Reporting (29–33%)
Exam Time: 3.5 hours—Any breaks taken will count Tasks:
against your exam time 1. Design metrics and criteria to meet the end users’ needs
through the collection and interpretation of data
DOMAIN 1 2. Generate routine and ad-hoc reports using internal
Data Management (30–34%) and external data sources to complete data requests
Tasks: 3. Present information in a concise, user-friendly format
1. Assist in the development and maintenance of the by determining target audience needs to support
data architecture and model to provide a foundation decision processes
for database design that supports the business’ needs 4. Provide recommendations based on analytical results
2. E
 stablish uniform definitions of data captured to improve business processes or outcomes
in source systems to create a reference tool (data
dictionary)
3. Formulate validation strategies and methods (i.e.,
system edits, reports, and audits) to ensure accurate
and reliable data
4. E
 valuate existing data structures using data tables and
field mapping to develop specifications that produce
accurate and properly reported data
5. I ntegrate data from internal or external sources in
order to provide data for analysis and/or reporting
6. Facilitate the update and maintenance of tables for
organization’s information systems in order to ensure
the quality and accuracy of the data

DOMAIN 2
Data Analytics (35–39%)
Tasks:
1. Analyze health data using appropriate testing meth-
ods to generate findings for interpretation
2. I nterpret analytical findings by formulating recom-
mendations for clinical, financial, and operational
processes
3. Validate results through qualitative and quantitative
analyses to confirm findings

36 Updated June 27, 2017 AHIMA CERTIFICATION CANDIDATE GUIDE


APPENDIX M
Certified in Healthcare Privacy and Security (CHPS) Examination Content Outline
Number of Questions on Exam: 8. Establish a preventative program to detect, prevent
• 150 multiple-choice (125 scored/25 pretest) and mitigate privacy/security breaches
Exam Time: 3.5 hours—Any breaks taken will count 9. Recommend appropriate de-identification
against your exam time methodologies
10. Verify that requesters of protected information are
DOMAIN 1 authorized and permitted to receive the protected
Ethical, Legal, and Regulatory Issues/ information (subpoena, court orders, search warrants)
Environmental Assessment (23–27%) 11. Define HIPAA-designated record sets for the organi-
zation in order to appropriately respond to a request
Tasks:
for release of information
1. Serve as a resource (provide guidance) to your
12. Identify information and record sets requiring special
organization regarding privacy and security laws,
privacy protections
regulations, and standards of accreditation agencies
to help interpret and apply the standards 13. Recommend, review and approve protocols to verify
identity and access rights of recipients/users of health
2. Demonstrate privacy and security compliance with
information
documentation, production, and retention as required
by State and Federal law as well as accrediting agencies 14. Establish, maintain, and ensure the distribution pro-
cess of the organization’s Notice of Privacy Practices
3. Identify responsibilities as a privacy officer and/or
security officer 15. Establish and maintain operational systems to receive,
process, and document requests for patients’ rights as
outlined in the Notice of Privacy Practices
DOMAIN 2
Program Management and Administration
(23–27%) DOMAIN 3
Information Technology/Physical and Technical
Tasks: Safeguards (23–27%)
1. Create, document, and communicate information
to include but not limited to minimum necessary Tasks:
protocols 1. Participate in the development and verify mainte-
nance of the inventory of software, hardware, and all
2. Manage contracts and business associate relationships
information assets to protect information assets and
and secure appropriate agreements related to privacy
to facilitate risk analysis
and security (e.g., BAA, SLA, etc.)
2. Participate in business continuity planning for
3. Evaluate and monitor facility security plan to safe-
planned downtime and contingency planning for
guard unauthorized physical access to information
emergencies and disaster recovery
and prevent theft or tampering
3. P
 articipate in evaluation, selection, and implementa-
4. Develop, deliver, evaluate, and document training
tion of information privacy and security solutions
and awareness on information privacy and security to
provide an informed workforce 4. I mplement a systematic process to evaluate risk to and
criticalities of information systems which contain PHI
5. W
 ork with appropriate organization officials to
verify that information used or disclosed for research 5. Participate in media control practices that govern
complies with organizational policies and procedures the receipt, removal, re-use, or disposal (internal and
and applicable privacy regulations external destruction) of any media or devices contain-
ing sensitive data
6. Assess, recommend, revise, and communicate changes
to organizational policies, procedures, and practices 6. Assess and monitor physical security mechanisms to
related to privacy and security limit the access of unauthorized personnel to facilities,
equipment and information
7. A
 ssess and communicate risks and ramifications of
privacy and security incidents, including those by 7. Establish reasonable safeguards to reduce incidental
business associates disclosures and prevent privacy breaches

AHIMA CERTIFICATION CANDIDATE GUIDE Updated June 27, 2017 37


APPENDIX M (continued)
Certified in Healthcare Privacy and Security (CHPS) Examination Content Outline
8. Participate in the development and management of 7. Coordinate mitigation efforts
the organization’s information security plan 8. D
 evelop policy and procedure for breach notification
9. Participate in the organizational risk analysis plan to (federal)
identify threats and vulnerabilities 9. Educate workforce on reporting requirements for
10. Monitor compliance with the security policies and breach notification (federal)
ensure compliance with technical, physical, and 10. Perform risk assessment for breach notification
administrative safeguards (federal)
11. Establish internal policies, procedures and rules to 11. Notify appropriate individuals/agencies/media within
protect information and participate in development time frame for breach notification (federal)
of guidelines, procedures and controls to ensure the
12. Maintain the appropriate documentation for breach
integrity, availability and confidentiality of communi-
notification (federal)
cation across networks
12. Ensure appropriate technologies are used to protect
information received from or transmitted to external
users
13. Advocate the use of event triggering to identify abnor-
mal conditions within a system (e.g. intrusion detec-
tion, denial of service, and invalid log-on attempts).
14. Establish and manage facilitate process for verifying
and controlling access authorizations, authentication
mechanisms, and privileges including emergency access
15. Evaluate the use of encryption for protected health
information and other sensitive data

DOMAIN 4
Investigation, Compliance, and Enforcement
(23–27%)
Tasks:
1. Monitor and assess compliance with state and federal
laws and regulations related to privacy and security to
update organizational practices, policies, procedures
and training of workforce
2. Coordinate the organization’s response to inquiries
and investigations from external entities relating to
privacy and security to provide response consistent
with organizational policies and procedures
3. Develop performance measures and reports to
monitor and improve organizational performance
and report to appropriate organizational body
4. Enforce privacy and security policies, procedures, and
guidelines to facilitate compliance with federal, state,
and other regulatory or accrediting bodies
5. Monitor access to protected health information
6. Establish an incident/complaint investigation
response, develop response plan, and identify team
members to respond to a privacy or security incident

38 Updated June 27, 2017 AHIMA CERTIFICATION CANDIDATE GUIDE


APPENDIX N
Certified Documentation Improvement Practitioner (CDIP) Examination
Content Outline
Number of questions on exam: DOMAIN 3
• 140 multiple-choice (106 scored/34 pretest) Record Review & Document Clarification
(24–28%)
Exam Time: 3 hours—Any breaks taken will count
against your exam time Tasks:
1. Identify opportunities for documentation improve-
DOMAIN 1 ment by ensuring that diagnoses and procedures are
Clinical Coding Practice (22–26%) documented to the highest level of specificity
Tasks: 2. Query providers in an ethical manner to avoid poten-
tial fraud and/or compliance issues
1. Use reference resources for code assignment
3. Formulate queries to providers to clarify conflicting
2. Identify the principal and secondary diagnoses in
diagnoses
order to accurately reflect the patient’s hospital course
4. Ensure provider query response is documented in the
3. Use coding software
medical record
4. Assign and sequence ICD-10-CM/PCS codes
5. Formulate queries to providers to clarify the clinical
5. Use coding conventions significance of abnormal findings identified in the
6. Display knowledge of Payer requirements for record
appropriate code assignment (e.g., CMS, APR, APG) 6. Track responses to queries and interact with providers
7. Assign appropriate DRG codes to obtain query responses
8. Communicate with the coding/HIM staff to resolve 7. Interact with providers to clarify POA
discrepancies between the working and final DRGs 8. I dentify post-discharge query opportunities that will
9. Participate in educational sessions with staff to discuss affect SOI, ROM and ultimately, case weight
infrequently encountered 9. Collaborate with the case management and utilization
10. Assign CPT and/or HCPCS codes review staff to affect change in documentation
11. Communicate with coding/HIM staff to resolve 10. Interact with providers to clarify HAC
discrepancies in documentation for CPT assignment 11. I nteract with providers to clarify the documentation
of core measures
DOMAIN 2 12. Interact with providers to clarify PSI
Leadership (17–22%)
13. Determine facility requirements for documentation
Tasks: of query responses in the record to establish official
1. Maintain affiliation with professional organizations policy and procedures related to CDI query activities
devoted to the accuracy of diagnosis coding and reporting 14. Develop policies regarding various stages of the query
2. Promote CDI efforts throughout the organization process and time frames to avoid compliance risk
3. Foster working relationship with CDI team members
for reconciliation of queries
4. Establish a chain of command for resolving unan-
swered queries
5. Develop documentation improvement projects
6. Collaborate with physician champions to promote
CDI initiatives
7. Establish consequences for noncompliance to queries or
lack of responses to queries in collaboration with providers
8. D
 evelop CDI policies and procedures in accordance
with AHIMA practice briefs

AHIMA CERTIFICATION CANDIDATE GUIDE Updated June 27, 2017 39


APPENDIX N (continued)
Certified Documentation Improvement Practitioner (CDIP) Examination
Content Outline
DOMAIN 4 6. Develop educational materials to facilitate
CDI Metrics & Statistics (14–18%) documentation that supports severity of illness, risk of
mortality, and utilization of resources
Tasks:
7. Research and adapts successful best practices within
1. Track denials and documentation practices to avoid the CDI specialty that could be utilized at one’s own
future denials organization
2. Trend and track physician query response
3. Track working DRG (CDS) and coder final code DOMAIN 6
4. Perform quality audits of CDI content to ensure Compliance (4–8%)
compliance with institutional policies and procedures
Tasks:
or national guidelines
1. Apply AHIMA best practices related to CDI activities
5. Trend and track physician query content
2. Apply regulations pertaining to CDI activities
6. Trend and track physician and query provider
3. Consult with compliance and HIM department
7. Trend and track physician query volume
regarding legal issues surrounding CDI efforts
8. M
 easure the success of the CDI program through
4. Monitor changes in the external regulatory
dashboard metrics
environment in order to maintain compliance
9. Track data for physician benchmarking and trending with all applicable agencies
10. Compare institution with external institutional 5. Educate the appropriate staff on the clinical
benchmarks documentation improvement program including
11. Track data for CDI benchmarking and trending accurate and ethical documentation practices
12. Track data for specialty benchmarking and trending 6. Develop educational materials to facilitate
13. Use CDI data to adjust departmental workflow documentation that supports severity of illness,
risk of mortality, and utilization of resources
7. Research and adapt successful best practices within
DOMAIN 5
the CDI specialty that could be utilized at one’s own
Research & Education (11–15%)
organization
Tasks:
1. Articulate the implications of accurate coding
2. Educate providers and other members of the health-
care team about the importance of the documentation
improvement program and the need to assign diag-
noses and procedures when indicated, to their highest
level of specificity
3. A
 rticulate the implications of accurate coding with
respect to research, public health reporting, case
management, and reimbursement
4. Monitor changes in the external regulatory
environment in order to maintain compliance with all
applicable agencies
5. Educate the appropriate staff on the clinical documen-
tation improvement program including accurate and
ethical documentation practices

40 Updated June 27, 2017 AHIMA CERTIFICATION CANDIDATE GUIDE


APPENDIX O
Certified Professional in Health Informatics (CPHI) Examination
Content Outline
DOMAIN 1 DOMAIN 4
DATA ANALYSIS AND UTILIZATION (13–17%) MANAGEMENT OF HEALTH INFORMATION
SYSTEMS AND PROCESSES (18–22%)
Tasks:
1. Gather report framework requirements Tasks:
2. Obtain data 1. Identify workflow processes
3. Aggregate data 2. Implement workflow processes
4. Validate/audit data 3. Design or customize templates
5. Manipulate data 4. Translate workflow into EHR configuration
6. Interpret data 5. Document clinical workflow
7. Interpret trends or patterns in data sets 6. Examine workflow compatibility with EHR systems
8. Work with management to prioritize business or 7. Work with organizational leadership to improve
information needs information processes
9. Conduct research with healthcare data to evaluate 8. Build interfaces with other applications internally and
quality or efficacy of health or health technology- externally
related outcomes or services
DOMAIN 5
DOMAIN 2 DATABASE MANAGEMENT (8–12%)
DATA REPORTING (13-17%) Tasks:
Tasks: 1. Analyze database to ensure accuracy and completeness
1. Identify data sources 2. Define healthcare related data structures
2. Conduct data mining 3. Develop terminology and taxonomy of health
3. Extract data from identified sources information systems
4. Standardize data 4. Ensure data meets industry or regulatory standards
5. Build data reports 5. Develop queries for recurring data extraction from
database
6. Design reports
6. Scrub data
7. Ensure standardization of templates and reports

DOMAIN 6
DOMAIN 3 INFORMATICS TRAINING (8–12%)
DATA MANAGEMENT, PRIVACY, AND SECURITY
(18-22%) Tasks:
Tasks: 1. Train clinicians on documentation
1. Secure data 2. Train help desk personnel on delegated tasks
2. Assist in defining access 3. Identify documentation error trends/deficiencies
3. Maintain access levels 4. Train users on efficient use of health information systems
4. Monitor access activities
5. Ensure data is mapped to schema
6. Apply integrity rules to ensure data
7. Submit reports to regulatory agencies
8. Perform security risk assessments
9. Manage the HIE
10. Assist in ROI
11. Deidentify PHI
AHIMA CERTIFICATION CANDIDATE GUIDE Updated October 21, 2016 41
APPENDIX O (continued)
Certified Professional in Health Informatics (CPHI) Examination
Content Outline
DOMAIN 7
PROJECT MANAGEMENT (8-12%)
Tasks:
1. Participate in the development of the project plan
2. Participate in the allocation of the project budgets
3. Integrate informatics into organizational workflow
4. Define the scope of the impact
5. Plan testing requirements
6. Participate in go/no go decisions
7. Coordinate implementation
8. Define support requirements
9. Develop test cases
10. Identify system resource requirements

42 Updated June 27, 2017 AHIMA CERTIFICATION CANDIDATE GUIDE


AHIMA CERTIFICATION CANDIDATE GUIDE Updated June 27, 2017 43
44 Updated June 27, 2017 AHIMA CERTIFICATION CANDIDATE GUIDE
Change History
Date Change
3/2/2016 Corrected pagination, grammatical errors, cosmetic updates, fixed broken links, created revision date footers,
changed 91 day waiting period to 45 days for CCA and CCS exams.
10/21/2016 Added Certified Professional in Health Informatics (CPHI) exam information

12/20/2016 1. Added PCAP Program to CCA eligibility criteria (page 5)


2. Added credential award date information for early-testers (page 14)
3. Added due date for submitting documentation for missing exam appointment (page 13)
4. Updated AHIMA membership application form
3/21/2017 1. Added NCCA seals to RHIA (page 4), RHIT (page 5), CCA (page 5), CCS (page 6), and CCS-P (page 6).
2. Replace closing parenthesis with opening parenthesis in the last paragraph of page 13.
3. Unbold “Diagnosis:” and “Procedure:” on pages 32 and 34.
4. Two blank pages added to the back, must be divisible by four to do a saddle stitch binding.
6/27/2017 1. Added e-mail address in transcript section of Contact Information
2. Added HIMR Proviso and Master’s level options to RHIA eligibility criteria
3. Updated exam application checklist

AHIMA CERTIFICATION CANDIDATE GUIDE Updated June 27, 2017


233 N. Michigan Ave., 21st Fl. • Chicago, IL 60601 • (312) 233-1100 • Fax: (312) 233-1500
Source Code: 897.17

Updated June 27, 2017 Updated June 27, 2017

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