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| Section | Weight | Objectives |
|---|---|---|
| Professionalism, ethics, and compliance | 9.17% | - Leading queries - CDI department goals beyond reimbursement - Potential DRG creep - Medical record confidentiality - Compliance risks indicated by PEPPER - DRG compliance initiatives |
| Healthcare facility CDI program analysis | 8.33% | - Publicly reported data - Patient Safety Indicators - Case mix index (CMI) - High-frequency DRGs - Severity of illness and risk of mortality - Hospital-specific financial data - Provider response rates - Tracking and trending physician, department, and hospital performance - CC/MCC capture - PEPPER data - Basic computer and software application skills - Physician performance measurement - CDI specialist productivity metrics - CDI program forecasting - Hospital Value-Based Purchasing measures |
| Healthcare regulations, reimbursement, and documentation requirements related to the IPPS | 12.5% | - Inpatient admission criteria and CMS Two-Midnight Rule - Medicare Severity Diagnosis Related Groups (MS-DRGs) - Major complication/comorbidity (MCC) - Case mix index (CMI) - Coding and billing practices vulnerable to denial - Principal diagnosis and medical necessity - Documentation impact on IPPS reimbursement - Documentation and medical necessity of setting - Complication/comorbidity (CC) - IPPS and its updates and revisions - Medicare contractors and their impact on CDI - Medical staff and clinical staff documentation responsibilities |
| Medical record documentation | 19.17% | - When a physician query is warranted - Situations in which queries are not appropriate - Compliant and noncompliant queries - Translating clinical indicators into compliant queries - Physician query formats - Addressing diagnoses without clinical support - Types of physician queries - Clinical indicators - Provider role and diagnosis code assignment - Health record elements used for diagnosis and procedure code assignment - ACDIS/AHIMA Guidelines for Achieving a Compliant Query Practice - Documentation requiring clarification |
| Anatomy and physiology, pathophysiology, pharmacology, and medical terminology | 19.17% | - Medications as clinical indicators - Diseases and disorders of the kidney and urinary tract - Diseases and disorders of the respiratory system - Diseases and disorders of the circulatory system - Diseases and disorders of the musculoskeletal system - Infectious and parasitic diseases - Endocrine, nutritional, and metabolic diseases and disorders - HIV infections - Pharmaceuticals and disease processes - Myeloproliferative diseases and disorders and poorly differentiated neoplasms - Diseases and disorders of the skin, subcutaneous tissue, and breast - Diseases and disorders of the nervous system - Alcohol/drug use and alcohol/drug-induced organic brain disorders - Injuries, poisonings, and toxic effects of drugs - Mental diseases and disorders - Diagnostic tests as clinical indicators - Diseases and disorders of the hepatobiliary system - Diseases and disorders of the blood and blood-forming organs and immunological disorders - Diseases and disorders of the digestive system - Standard medical abbreviations - Clinical indicators and query opportunities by Major Diagnostic Category |
| Communication skills | 9.17% | - Roles and responsibilities of CDI specialists - Educational presentations for healthcare departments and administration - Reconciling CDI working DRGs with final coded DRGs - Verbal versus written physician communication - Effective and non-confrontational physician communication - Roles and responsibilities of coders working with CDI departments - Physician education forms and tools |
| Official Guidelines for Coding and Reporting | 14.17% | - AHA Coding Clinic - Coding guidelines for principal diagnosis selection - Principal diagnosis assignment - Official Guidelines for Coding and Reporting updates - Present on admission indicators - Hospital-acquired conditions - Working DRG assignment for multiple diagnoses - Discharge dispositions and transfers - Secondary diagnosis assignment |
| Impact of reportable diagnoses on quality of care | 8.33% | - Patient Safety Indicators - 30-day mortality measures - Hospital Readmissions Reduction Program - Coded data elements affecting Patient Safety Indicators - Quality data from record abstraction and claims data - Hospital-Acquired Condition Reduction Program - Documentation and code assignment impact on mortality index - Mortality reviews and observed/expected ratios - Healthcare-associated infections and complication codes - Hospital Inpatient Quality Reporting Program - CDI impact on Hospital Value-Based Purchasing - Hospital Value-Based Purchasing |
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NEW QUESTION # 62
A patient is admitted with hypertension and stage 3b chronic kidney disease. The physician does not explicitly state that the CKD is caused by hypertension. The record contains no documentation indicating that the two conditions are unrelated. Which of the following is the MOST appropriate approach when assigning the working diagnoses?
Answer: B
Explanation:
ICD-10-CM presumes a causal relationship between hypertension and chronic kidney disease when both are documented, unless the provider specifically states that the conditions are unrelated. Therefore, the working coding logic should recognize hypertensive CKD and additionally identify the patient's CKD stage.
The FY 2026 Official Guidelines direct assignment of a code from category I12, Hypertensive chronic kidney disease, when hypertension and a condition classified to N18.- are both present. An additional N18.- code is required to identify the CKD stage. In this case, the documented stage is 3b.
A provider query solely to establish the hypertension-CKD relationship is unnecessary because ICD-10-CM itself supplies the presumed relationship. However, a query could become necessary if the physician explicitly states or strongly suggests that the CKD is unrelated to hypertension or if conflicting documentation exists.
The CDI specialist must distinguish coding conventions that automatically establish certain relationships from situations in which provider linkage is mandatory. This prevents unnecessary queries and supports accurate working-DRG assignment.
CCDS Reference Topics: Hypertensive CKD; presumed causal relationships; CKD staging; coding conventions; working MS-DRG.
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NEW QUESTION # 63
A patient presents with fever, productive cough, and infiltrates in the right upper lobe per chest x-ray. The history and physical notes that the patient has pneumonia and hypotension. Cultures are drawn and the patient is admitted for IV antibiotics. On day 2, the patient's condition worsens, and the patient is transferred to the ICU for closer monitoring. The ICU physician documents sepsis. Which of the following statements is MOST accurate?
Answer: A
Explanation:
The key issue is whether the sepsis documented on hospital day 2 was present on admission (POA) or developed after admission. The admission already contains potentially relevant indicators-fever, pneumonia, hypotension, cultures, and IV antibiotic treatment-but a CDI specialist cannot independently determine from those indicators that sepsis was POA. Provider clarification is necessary.
This distinction directly affects principal-diagnosis sequencing. When sepsis and a localized infection such as pneumonia are both responsible for admission, the systemic infection is generally sequenced before the localized infection. Conversely, when the patient is admitted with pneumonia and sepsis develops only after admission, pneumonia is sequenced first.
The POA guidelines also emphasize that a diagnosis may not be recognized until days after admission and that delayed documentation does not automatically mean the condition was hospital-acquired. When timing is unclear, querying the provider is appropriate.
There is no evidence supporting aspiration pneumonia, so option B would introduce an unsupported concept.
Options C and D prematurely determine principal diagnosis without resolving the timing of sepsis.
CCDS Reference Topics: Sepsis sequencing; POA assignment; principal diagnosis; compliant clarification of timing.
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NEW QUESTION # 64
A CDI manager is evaluating physician participation in the program. Which metric most strongly indicates poor physician engagement?
Answer: D
Explanation:
A high volume of unanswered queries most directly indicates inadequate provider engagement. This question is adapted from the current ACDIS Candidate Handbook's publicly released CCDS sample questions.
A provider may legitimately agree or disagree with a CDI query. Disagreement does not necessarily indicate poor engagement because the purpose of a query is clarification, not obtaining a predetermined diagnosis. A physician who reviews the clinical information and documents that the condition is ruled out, clinically undetermined, or otherwise different from the proposed possibilities is still participating appropriately.
Likewise, the number of queries generated is primarily a CDI workload or opportunity metric. It does not demonstrate whether physicians are responding.
A persistent nonresponse rate is more concerning because unanswered queries can delay final coding, create unresolved ambiguity, affect billing timeliness, reduce documentation completeness, and indicate weaknesses in provider communication or organizational query escalation procedures.
A CDI manager should not evaluate engagement from a single metric in isolation. Response time, response rate, education participation, documentation trends, service-line differences, and escalation frequency provide additional useful context.
CCDS Reference Topics: Physician engagement; query-response metrics; CDI analytics; program effectiveness.
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NEW QUESTION # 65
A CDI specialist submits a neutral query regarding possible acute blood loss anemia. The physician answers
"clinically unable to determine." The CDI specialist believes documenting the diagnosis would increase reimbursement substantially. What is the MOST appropriate next action?
Answer: B
Explanation:
The provider's response should be respected unless new information or a genuine unresolved documentation issue creates a legitimate reason for additional clarification.
"Clinically unable to determine" is an acceptable professional conclusion when the available evidence does not permit the provider to confidently establish a diagnosis. A CDI specialist must not continue sending essentially the same query simply because a different response would produce more favorable reimbursement.
Likewise, CDI cannot alter the provider's response or instruct coding personnel to assign a diagnosis that the provider declined to establish.
The 2026 ACDIS/AHIMA Guidelines for Achieving a Compliant Query Practice supersede all previous versions and serve as the current foundational resource for query processes. The query process is intended to improve the accuracy, completeness, and integrity of documentation-not to secure a predetermined financial result.
A legitimate follow-up could occur if new laboratory values, operative findings, transfusion information, pathology, or other material information emerges after the original response and creates a materially different clarification question.
Professional CDI practice requires balancing clinical advocacy with provider autonomy, ethical conduct, and regulatory compliance.
CCDS Reference Topics: Provider query responses; ethical CDI practice; repeated queries; provider independence; compliance.
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NEW QUESTION # 66
A patient presents with crushing substernal chest pain, diaphoresis, ST-segment depression, and a significant rise and fall in cardiac troponin. The cardiologist documents acute coronary syndrome but does not specify the final diagnosis. Which clarification is MOST clinically appropriate?
Answer: C
Explanation:
The clinical picture presents an appropriate opportunity to clarify whether the patient has NSTEMI, unstable angina, or another acute coronary diagnosis.
A significant rise and/or fall in cardiac troponin consistent with acute myocardial injury, together with ischemic symptoms and ECG abnormalities, strongly raises concern for acute myocardial infarction. In contrast, unstable angina generally refers to ischemia without the biomarker evidence required for myocardial infarction.
Nevertheless, CDI should not make the diagnosis independently. Troponin elevations can occur in multiple conditions, including myocarditis, pulmonary embolism, sepsis, tachyarrhythmia, renal disease, and other forms of myocardial injury.
Therefore, the cardiologist should be asked to clarify the final diagnosis based on the complete clinical evaluation.
GERD, chronic stable angina, and old MI do not adequately reflect the acute findings described.
For CCDS preparation, cardiovascular questions frequently require distinguishing symptoms from established diagnoses and understanding the clinical indicators associated with NSTEMI, STEMI, type 2 MI, and other myocardial injury categories.
The ACDIS candidate handbook identifies anatomy, physiology, pharmacology, pathophysiology, and clinical record analysis as essential examination competencies.
CCDS Reference Topics: NSTEMI; acute coronary syndrome; troponin; myocardial ischemia; diagnostic clarification.
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NEW QUESTION # 67
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