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| Section | Weight | Objectives |
|---|---|---|
| Professionalism, ethics, and compliance | 9.17% | - DRG compliance initiatives - CDI department goals beyond reimbursement - Leading queries - Medical record confidentiality - Potential DRG creep - Compliance risks indicated by PEPPER |
| Healthcare regulations, reimbursement, and documentation requirements related to the IPPS | 12.5% | - Documentation and medical necessity of setting - IPPS and its updates and revisions - Case mix index (CMI) - Complication/comorbidity (CC) - Coding and billing practices vulnerable to denial - Principal diagnosis and medical necessity - Medicare contractors and their impact on CDI - Medical staff and clinical staff documentation responsibilities - Major complication/comorbidity (MCC) - Medicare Severity Diagnosis Related Groups (MS-DRGs) - Documentation impact on IPPS reimbursement - Inpatient admission criteria and CMS Two-Midnight Rule |
| Anatomy and physiology, pathophysiology, pharmacology, and medical terminology | 19.17% | - Diseases and disorders of the respiratory system - Pharmaceuticals and disease processes - Diseases and disorders of the musculoskeletal system - Mental diseases and disorders - Alcohol/drug use and alcohol/drug-induced organic brain disorders - Endocrine, nutritional, and metabolic diseases and disorders - Diseases and disorders of the nervous system - Diseases and disorders of the digestive system - Medications as clinical indicators - Diseases and disorders of the hepatobiliary system - Diagnostic tests as clinical indicators - Myeloproliferative diseases and disorders and poorly differentiated neoplasms - Infectious and parasitic diseases - Diseases and disorders of the circulatory system - Injuries, poisonings, and toxic effects of drugs - HIV infections - Clinical indicators and query opportunities by Major Diagnostic Category - Standard medical abbreviations - Diseases and disorders of the blood and blood-forming organs and immunological disorders - Diseases and disorders of the skin, subcutaneous tissue, and breast - Diseases and disorders of the kidney and urinary tract |
| Official Guidelines for Coding and Reporting | 14.17% | - Principal diagnosis assignment - Official Guidelines for Coding and Reporting updates - Working DRG assignment for multiple diagnoses - Hospital-acquired conditions - Secondary diagnosis assignment - Discharge dispositions and transfers - Coding guidelines for principal diagnosis selection - Present on admission indicators - AHA Coding Clinic |
| Healthcare facility CDI program analysis | 8.33% | - Hospital-specific financial data - Severity of illness and risk of mortality - Tracking and trending physician, department, and hospital performance - CDI program forecasting - Case mix index (CMI) - CC/MCC capture - PEPPER data - Patient Safety Indicators - Basic computer and software application skills - Physician performance measurement - High-frequency DRGs - Provider response rates - CDI specialist productivity metrics - Publicly reported data - Hospital Value-Based Purchasing measures |
| Communication skills | 9.17% | - Physician education forms and tools - Roles and responsibilities of coders working with CDI departments - Verbal versus written physician communication - Roles and responsibilities of CDI specialists - Educational presentations for healthcare departments and administration - Reconciling CDI working DRGs with final coded DRGs - Effective and non-confrontational physician communication |
| Impact of reportable diagnoses on quality of care | 8.33% | - Hospital-Acquired Condition Reduction Program - Healthcare-associated infections and complication codes - Documentation and code assignment impact on mortality index - 30-day mortality measures - Coded data elements affecting Patient Safety Indicators - Mortality reviews and observed/expected ratios - Patient Safety Indicators - Hospital Value-Based Purchasing - CDI impact on Hospital Value-Based Purchasing - Hospital Readmissions Reduction Program - Quality data from record abstraction and claims data - Hospital Inpatient Quality Reporting Program |
| Medical record documentation | 19.17% | - Types of physician queries - Health record elements used for diagnosis and procedure code assignment - Translating clinical indicators into compliant queries - Provider role and diagnosis code assignment - Physician query formats - Compliant and noncompliant queries - When a physician query is warranted - Documentation requiring clarification - Clinical indicators - ACDIS/AHIMA Guidelines for Achieving a Compliant Query Practice - Situations in which queries are not appropriate - Addressing diagnoses without clinical support |
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NEW QUESTION # 112
A patient experienced a type 1 STEMI 10 days ago. The patient is readmitted and develops a new type 1 NSTEMI during the four-week acute myocardial infarction period. Which ICD-10-CM concept applies?
Answer: B
Explanation:
ICD-10-CM provides category I22 for a subsequent acute myocardial infarction occurring within four weeks-28 days-of an initial acute MI, when the qualifying MI types and circumstances meet the classification requirements.
The FY 2026 Official Guidelines specify that when a patient with a type 1 or unspecified acute MI experiences a new type 1 or unspecified MI within four weeks of the initial MI, a code from category I22 is used together with the appropriate I21 code. Sequencing depends on the circumstances of the encounter.
This rule requires care because type 2 MI and certain other myocardial infarction classifications do not follow the same I22 subsequent-MI logic. CDI specialists therefore need accurate documentation of MI type, anatomic location when applicable, timing, and whether the current event represents a genuinely new infarction rather than ongoing care for the original MI.
The prior STEMI does not become an "old MI" merely because the patient left the hospital; the ICD-10-CM acute MI period extends for four weeks from onset.
CCDS Reference Topics: Acute MI; subsequent MI; I21/I22; four-week rule; cardiovascular coding.
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NEW QUESTION # 113
Which CMS resource contains the complete FY 2026 lists of diagnoses classified as MCCs and CCs for MS- DRG purposes?
Answer: A
Explanation:
CMS publishes the complete MCC and CC lists as part of the FY 2026 IPPS Final Rule supporting tables.
Specifically, the FY 2026 final-rule page identifies Table 6I as the Complete MCC List and Table 6J as the Complete CC List, along with additions, deletions, and the CC exclusion list.
These files are critical reference resources when assessing MS-DRG severity logic. Nevertheless, classification as an MCC or CC does not automatically mean that the diagnosis changes a particular case's MS-DRG. Principal-diagnosis exclusions, procedure logic, DRG structure, and the presence of another MCC can affect whether a diagnosis alters final assignment.
The Hospital Consumer Assessment survey relates to patient experience rather than diagnosis severity classification. The Physician Fee Schedule governs professional reimbursement and does not contain the inpatient MS-DRG MCC/CC classification system. National Coverage Determinations address Medicare coverage for particular services rather than MS-DRG severity categories.
CDI specialists should use the current CMS version applicable to the discharge date. CMS identifies MS- DRG Version 43.1 as effective April 1 through September 30, 2026.
CCDS Reference Topics: MCC; CC; CMS Definitions Manual; IPPS; MS-DRG severity.
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NEW QUESTION # 114
A patient is admitted with nausea, confusion, and generalized weakness. Laboratory testing shows a serum sodium level of 119 mEq/L. The patient receives hypertonic saline and frequent serum sodium monitoring.
The physician documents "electrolyte disturbance." Which condition is the MOST appropriate clarification opportunity?
Answer: A
Explanation:
The clinical findings strongly support clarification of hyponatremia. A serum sodium concentration of 119 mEq/L represents substantial reduction below the usual reference range, and neurologic manifestations such as confusion are consistent with clinically significant hyponatremia. Administration of hypertonic saline and frequent sodium monitoring further demonstrate that the electrolyte abnormality is clinically important.
The CDI specialist should not independently assign the diagnosis based solely on the laboratory result.
Instead, the abnormal sodium level, neurologic symptoms, and targeted therapy provide an appropriate clinical basis for a neutral provider query.
Hypernatremia represents elevated serum sodium and therefore contradicts the laboratory finding.
Hyperkalemia relates to potassium rather than sodium. Metabolic alkalosis is an acid-base disturbance requiring supporting blood-gas and chemistry findings and is not established by the information provided.
Further specificity may also matter. Depending on the clinical record, the physician may determine that the hyponatremia is related to SIADH, volume depletion, medication use, heart failure, cirrhosis, or another etiology.
The CCDS role is to recognize the clinical significance of laboratory abnormalities and obtain clinically meaningful provider documentation rather than simply translating abnormal values into diagnoses.
CCDS Reference Topics: Electrolyte abnormalities; hyponatremia; laboratory interpretation; clinical indicators; documentation clarification.
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NEW QUESTION # 115
Under the FY 2026 Hospital-Acquired Condition Reduction Program, which hospitals are subject to the program's payment reduction?
Answer: B
Explanation:
Under the FY 2026 Hospital-Acquired Condition Reduction Program (HACRP), applicable subsection (d) hospitals in the worst-performing quartile based on the Total HAC Score receive a 1% payment reduction on applicable Medicare fee-for-service payments. CMS defines the worst-performing quartile as hospitals whose Total HAC Score is above the 75th percentile.
The FY 2026 program incorporates the CMS Patient Safety and Adverse Events Composite (PSI 90) plus five healthcare-associated infection measures: CLABSI, CAUTI, specified surgical-site infection, MRSA bacteremia, and C. difficile infection.
A single HAC does not automatically trigger the hospital-wide 1% HACRP reduction. Likewise, CMI is not the criterion used to determine HACRP penalties.
It is also important for CCDS candidates to distinguish the HAC Reduction Program from the separate DRA HAC/POA payment provision. CMS explicitly identifies them as distinct programs.
Accurate documentation and coding are important because quality measures rely on reliable clinical data, but CDI activity must remain focused on accurately representing the clinical record rather than manipulating quality metrics.
CCDS Reference Topics: HAC Reduction Program; PSI 90; HAI measures; quality payment; hospital performance.
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NEW QUESTION # 116
A patient is admitted with a documented diagnosis of acute hypoxic respiratory failure. Which of the following clinical data BEST supports the diagnosis?
Answer: C
Explanation:
Option A provides the strongest clinical support for acute hypoxic respiratory failure because it demonstrates substantial respiratory distress and progressive need for oxygen/ventilatory support. Tripod positioning is an objective sign of increased work of breathing. Escalation to a non-rebreather mask indicates a substantial oxygen requirement, and subsequent endotracheal intubation demonstrates failure of less invasive respiratory support.
Acute respiratory failure is ultimately a provider diagnosis, and no single oxygen-saturation threshold establishes it in every patient. A CDI specialist therefore evaluates the entire clinical picture: oxygenation, baseline respiratory status, work of breathing, arterial blood gases when available, escalating oxygen requirements, ventilatory support, and treatment intensity.
An SaO# of 91% on low-flow oxygen may represent clinically important hypoxemia, but without additional evidence it is less compelling than the severe respiratory compromise described in option A. Likewise, a patient with COPD who chronically uses 2 L/min oxygen and maintains an SaO# of 94% may simply be at baseline.
FY 2026 ICD-10-CM guidance recognizes acute respiratory failure as a reportable diagnosis and permits it as principal or secondary depending on the circumstances of admission.
CCDS Reference Topics: Respiratory failure; clinical indicators; pathophysiology; clinical validation.
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NEW QUESTION # 117
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