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| Section | Weight | Objectives |
|---|---|---|
| Anatomy and physiology, pathophysiology, pharmacology, and medical terminology | 19.17% | - Myeloproliferative diseases and disorders and poorly differentiated neoplasms - HIV infections - Standard medical abbreviations - Diseases and disorders of the skin, subcutaneous tissue, and breast - Diseases and disorders of the blood and blood-forming organs and immunological disorders - Clinical indicators and query opportunities by Major Diagnostic Category - Diseases and disorders of the musculoskeletal system - Injuries, poisonings, and toxic effects of drugs - Medications as clinical indicators - Mental diseases and disorders - Diseases and disorders of the digestive system - Diseases and disorders of the respiratory system - Alcohol/drug use and alcohol/drug-induced organic brain disorders - Endocrine, nutritional, and metabolic diseases and disorders - Diagnostic tests as clinical indicators - Diseases and disorders of the kidney and urinary tract - Diseases and disorders of the circulatory system - Infectious and parasitic diseases - Diseases and disorders of the hepatobiliary system - Pharmaceuticals and disease processes - Diseases and disorders of the nervous system |
| Communication skills | 9.17% | - Verbal versus written physician communication - Reconciling CDI working DRGs with final coded DRGs - Effective and non-confrontational physician communication - Roles and responsibilities of CDI specialists - Educational presentations for healthcare departments and administration - Physician education forms and tools - Roles and responsibilities of coders working with CDI departments |
| Healthcare facility CDI program analysis | 8.33% | - Provider response rates - Publicly reported data - Hospital Value-Based Purchasing measures - Physician performance measurement - CDI specialist productivity metrics - PEPPER data - Case mix index (CMI) - Hospital-specific financial data - High-frequency DRGs - Basic computer and software application skills - CC/MCC capture - Tracking and trending physician, department, and hospital performance - Severity of illness and risk of mortality - Patient Safety Indicators - CDI program forecasting |
| Impact of reportable diagnoses on quality of care | 8.33% | - Hospital-Acquired Condition Reduction Program - 30-day mortality measures - Hospital Inpatient Quality Reporting Program - Coded data elements affecting Patient Safety Indicators - Mortality reviews and observed/expected ratios - CDI impact on Hospital Value-Based Purchasing - Hospital Value-Based Purchasing - Hospital Readmissions Reduction Program - Documentation and code assignment impact on mortality index - Quality data from record abstraction and claims data - Healthcare-associated infections and complication codes - Patient Safety Indicators |
| Medical record documentation | 19.17% | - Provider role and diagnosis code assignment - Situations in which queries are not appropriate - Types of physician queries - Addressing diagnoses without clinical support - Health record elements used for diagnosis and procedure code assignment - Documentation requiring clarification - Compliant and noncompliant queries - Translating clinical indicators into compliant queries - Physician query formats - Clinical indicators - When a physician query is warranted - ACDIS/AHIMA Guidelines for Achieving a Compliant Query Practice |
| Healthcare regulations, reimbursement, and documentation requirements related to the IPPS | 12.5% | - Medicare contractors and their impact on CDI - Coding and billing practices vulnerable to denial - Major complication/comorbidity (MCC) - Documentation impact on IPPS reimbursement - Inpatient admission criteria and CMS Two-Midnight Rule - Case mix index (CMI) - Documentation and medical necessity of setting - Principal diagnosis and medical necessity - Medicare Severity Diagnosis Related Groups (MS-DRGs) - IPPS and its updates and revisions - Medical staff and clinical staff documentation responsibilities - Complication/comorbidity (CC) |
| Professionalism, ethics, and compliance | 9.17% | - CDI department goals beyond reimbursement - Compliance risks indicated by PEPPER - DRG compliance initiatives - Leading queries - Potential DRG creep - Medical record confidentiality |
| Official Guidelines for Coding and Reporting | 14.17% | - Principal diagnosis assignment - Working DRG assignment for multiple diagnoses - Present on admission indicators - Official Guidelines for Coding and Reporting updates - Coding guidelines for principal diagnosis selection - Secondary diagnosis assignment - AHA Coding Clinic - Hospital-acquired conditions - Discharge dispositions and transfers |
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16. Frage
A patient is admitted with pneumonia. On hospital day 3, the patient deteriorates and the physician documents that sepsis developed after admission as a consequence of the pneumonia. Which diagnosis is generally sequenced first?
Antwort: D
Begründung:
When a patient is admitted with a localized infection and sepsis develops after admission, the localized infection is generally sequenced as the principal diagnosis, followed by the appropriate sepsis code.
The FY 2026 ICD-10-CM Official Guidelines explicitly distinguish this circumstance from cases in which both the localized infection and sepsis are present on admission. When sepsis develops only after admission, the localized infection responsible for the original hospitalization remains principal.
Therefore, pneumonia is sequenced first in this scenario.
If the patient subsequently develops acute organ dysfunction related to sepsis and the provider documents severe sepsis, additional severe-sepsis and organ-dysfunction codes are assigned as appropriate. The severe- sepsis code cannot itself serve as principal diagnosis.
This question demonstrates why CDI specialists must clarify timing. Simply seeing both "pneumonia" and
"sepsis" in a discharge summary is insufficient to determine correct sequencing when the onset relationship is unclear.
The POA status of sepsis also becomes relevant because documentation indicates that it developed after inpatient admission.
CCDS Reference Topics: Sepsis; pneumonia; sequencing; timing; POA; principal diagnosis.
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17. Frage
Each MS-DRG has a relative weight (RW). RW is primarily associated with which of the following?
Antwort: A
Begründung:
An MS-DRG relative weight is primarily a measure of relative resource consumption. CMS explains that each MS-DRG is assigned a payment weight representing the average resources required to treat cases in that MS- DRG relative to the average resources required for cases across all DRGs.
A relative weight greater than 1.0 generally represents a case group expected to consume more resources than the overall Medicare inpatient average, whereas a weight below 1.0 reflects comparatively lower expected resource utilization. CMS recalibrates MS-DRG relative weights periodically using national cost and claims information.
Severity of illness often correlates with resource consumption because clinically complex patients commonly require additional diagnostics, monitoring, interventions, medications, procedures, and length of stay.
Nevertheless, severity of illness is not itself the definition of relative weight.
Hospital quality measures are evaluated through separate quality programs. Likewise, an individual hospital's billed charges do not directly define the MS-DRG relative weight assigned nationally, although standardized cost and charge data contribute to CMS's broader methodology for recalibrating weights.
Understanding relative weight is essential for CDI because documentation affects code and MS-DRG assignment, while the MS-DRG's relative weight influences the standardized IPPS payment calculation.
CCDS Reference Topics: MS-DRG relative weight; IPPS methodology; resource utilization; reimbursement fundamentals.
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18. Frage
A CDI specialist reviews a prior hospitalization and finds that the patient previously had chronic systolic heart failure. During the current admission, the provider documents only "history of CHF," although the patient remains on long-term heart-failure therapy. What is the BEST approach?
Antwort: A
Begründung:
Prior-encounter information may provide valuable clinical context, but it should not automatically be imported as a current reportable diagnosis without considering whether the condition remains active and relevant to the present encounter.
Here, a prior diagnosis of chronic systolic heart failure, ongoing heart-failure therapy, and ambiguous current wording such as "history of CHF" create a reasonable opportunity to clarify the patient's current heart-failure status if that information is clinically relevant.
The CDI specialist should not independently carry forward the previous diagnosis or escalate it to acute heart failure. Conversely, rigidly ignoring reliable prior clinical information can prevent identification of legitimate documentation gaps.
The 2026 ACDIS/AHIMA query guidance specifically includes the role of prior encounters as part of its updated query-practice framework, while emphasizing compliant provider clarification and accurate representation of the current patient's clinical status.
A query should make clear which current clinical indicators support the need for clarification and should not imply that a previous diagnosis must automatically remain valid.
CCDS Reference Topics: Prior encounters; chronic conditions; heart failure; query practice; current- encounter documentation.
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19. Frage
A patient undergoes abdominal surgery. Two days later, the physician documents "postoperative anemia." The hemoglobin decreased from 12.4 g/dL preoperatively to 8.2 g/dL, but the record does not state whether the anemia represents an expected postoperative condition, acute blood loss anemia, or a complication of surgery. What should the CDI specialist do?
Antwort: C
Begründung:
The appropriate action is to query for clarification. A temporal relationship-anemia occurring after surgery- does not automatically establish that a reportable complication occurred. Likewise, a CDI specialist cannot independently translate a substantial hemoglobin decline into acute posthemorrhagic anemia without provider documentation.
The FY 2026 Official Guidelines state that complication-of-care code assignment depends on provider documentation establishing the relationship between the condition and the care or procedure unless the classification specifically instructs otherwise. They also emphasize that not every condition occurring during or following medical care is a complication.
The query could present the preoperative and postoperative hemoglobin values, estimated blood loss, transfusions, clinical monitoring, and treatment. Appropriate response options might include acute blood loss anemia, expected postoperative anemia, another diagnosis, or clinically unable to determine, depending on the record.
Option A overstates causation. Option B independently diagnoses the patient from laboratory findings. Option D is equally inappropriate because clinically significant postoperative anemia may be reportable.
CCDS Reference Topics: Complications of care; postoperative anemia; clinical indicators; cause-and-effect clarification; compliant querying.
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20. Frage
A hospital has a total MS-DRG relative weight of 2,640 for 1,600 inpatient discharges. What is its case mix index?
Antwort: A
Begründung:
Case mix index is calculated by dividing the sum of MS-DRG relative weights by the number of inpatient discharges:
2,640 ÷ 1,600 = 1.65
Therefore, the CMI is 1.65.
CMI represents the average relative resource intensity of the hospital's inpatient cases. It is affected by the types of patients treated, surgical versus medical mix, tertiary services, transplant or trauma volume, documentation specificity, coding accuracy, and annual changes to MS-DRG relative weights and grouper logic.
CMS publishes hospital case-mix information and FY 2026 relative weighting factors through the IPPS Final Rule supporting data. Table 5 contains MS-DRGs and relative weighting factors, while Table 2 contains hospital-specific case-mix information.
A decline in CMI should not automatically be interpreted as a CDI failure. A shift toward lower-complexity cases or changes in service lines can legitimately reduce CMI even with excellent documentation.
CDI managers should therefore trend CMI alongside diagnosis capture, surgical volume, service lines, payer population, coding reconciliation, and quality indicators.
CCDS Reference Topics: Case mix index; MS-DRG relative weight; CDI analytics; hospital performance.
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21. Frage
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CCDS Fragen Und Antworten: https://www.pass4test.de/CCDS.html