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| Section | Weight | Objectives |
|---|---|---|
| Topic 1: Anatomy and physiology, pathophysiology, pharmacology, and medical terminology | 19.17% | - Medications as clinical indicators - Injuries, poisonings, and toxic effects of drugs - Diseases and disorders of the skin, subcutaneous tissue, and breast - Mental diseases and disorders - Infectious and parasitic diseases - Diseases and disorders of the musculoskeletal system - Clinical indicators and query opportunities by Major Diagnostic Category - Pharmaceuticals and disease processes - Endocrine, nutritional, and metabolic diseases and disorders - Standard medical abbreviations - Diseases and disorders of the nervous system - Diseases and disorders of the kidney and urinary tract - Diseases and disorders of the respiratory system - Myeloproliferative diseases and disorders and poorly differentiated neoplasms - Alcohol/drug use and alcohol/drug-induced organic brain disorders - Diseases and disorders of the circulatory system - Diseases and disorders of the hepatobiliary system - Diagnostic tests as clinical indicators - Diseases and disorders of the digestive system - HIV infections - Diseases and disorders of the blood and blood-forming organs and immunological disorders |
| Topic 2: Communication skills | 9.17% | - Verbal versus written physician communication - Roles and responsibilities of CDI specialists - Physician education forms and tools - Educational presentations for healthcare departments and administration - Effective and non-confrontational physician communication - Reconciling CDI working DRGs with final coded DRGs - Roles and responsibilities of coders working with CDI departments |
| Topic 3: Impact of reportable diagnoses on quality of care | 8.33% | - Quality data from record abstraction and claims data - Healthcare-associated infections and complication codes - 30-day mortality measures - Patient Safety Indicators - Documentation and code assignment impact on mortality index - Hospital Inpatient Quality Reporting Program - Hospital-Acquired Condition Reduction Program - Coded data elements affecting Patient Safety Indicators - CDI impact on Hospital Value-Based Purchasing - Hospital Value-Based Purchasing - Mortality reviews and observed/expected ratios - Hospital Readmissions Reduction Program |
| Topic 4: Professionalism, ethics, and compliance | 9.17% | - Leading queries - Medical record confidentiality - Potential DRG creep - CDI department goals beyond reimbursement - DRG compliance initiatives - Compliance risks indicated by PEPPER |
| Topic 5: Healthcare facility CDI program analysis | 8.33% | - High-frequency DRGs - Physician performance measurement - Severity of illness and risk of mortality - Case mix index (CMI) - Patient Safety Indicators - CDI specialist productivity metrics - Hospital-specific financial data - Tracking and trending physician, department, and hospital performance - Publicly reported data - CC/MCC capture - CDI program forecasting - Hospital Value-Based Purchasing measures - Basic computer and software application skills - Provider response rates - PEPPER data |
| Topic 6: Official Guidelines for Coding and Reporting | 14.17% | - Coding guidelines for principal diagnosis selection - Discharge dispositions and transfers - Present on admission indicators - Principal diagnosis assignment - Hospital-acquired conditions - Secondary diagnosis assignment - Official Guidelines for Coding and Reporting updates - AHA Coding Clinic - Working DRG assignment for multiple diagnoses |
| Topic 7: Healthcare regulations, reimbursement, and documentation requirements related to the IPPS | 12.5% | - Inpatient admission criteria and CMS Two-Midnight Rule - IPPS and its updates and revisions - Medical staff and clinical staff documentation responsibilities - Case mix index (CMI) - Major complication/comorbidity (MCC) - Documentation impact on IPPS reimbursement - Medicare contractors and their impact on CDI - Medicare Severity Diagnosis Related Groups (MS-DRGs) - Principal diagnosis and medical necessity - Coding and billing practices vulnerable to denial - Documentation and medical necessity of setting - Complication/comorbidity (CC) |
| Topic 8: Medical record documentation | 19.17% | - Translating clinical indicators into compliant queries - Provider role and diagnosis code assignment - Documentation requiring clarification - Compliant and noncompliant queries - Addressing diagnoses without clinical support - ACDIS/AHIMA Guidelines for Achieving a Compliant Query Practice - Physician query formats - Types of physician queries - Clinical indicators - Health record elements used for diagnosis and procedure code assignment - When a physician query is warranted - Situations in which queries are not appropriate |
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NEW QUESTION # 29
A patient is admitted with hypertension and acute systolic heart failure. The provider does not explicitly link the two conditions and does not state that they are unrelated. Which coding principle applies?
Answer: A
Explanation:
ICD-10-CM presumes a causal relationship between hypertension and qualifying heart disease, including heart failure, because the conditions are linked under "hypertension, with" in the Alphabetic Index. The presumed relationship applies unless the provider clearly documents that the heart disease is unrelated to hypertension.
Accordingly, hypertensive heart disease is coded using the appropriate I11.- category, with an additional I50.- code identifying the specific type and acuity of heart failure.
This convention differs from conditions for which ICD-10-CM does not provide a presumed causal link. In those circumstances, provider documentation must explicitly establish the relationship.
The CDI specialist therefore should not routinely query merely to obtain wording such as "hypertensive heart failure" when both hypertension and a qualifying heart-failure diagnosis are already documented and no statement says they are unrelated.
However, CDI may still need clarification when heart-failure type or acuity is incomplete, documentation is contradictory, or the physician expressly disputes a hypertensive relationship.
Recognizing these classification-based presumptions reduces unnecessary queries and supports accurate working-code and MS-DRG assignment.
CCDS Reference Topics: Hypertensive heart disease; heart failure; presumed relationships; coding conventions; query necessity.
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NEW QUESTION # 30
A hospital's query policy states that all answered queries will be retained, but all unanswered queries that might delay billing will be permanently destroyed. What is the PRIMARY compliance concern?
Answer: B
Explanation:
The principal concern is the selective destruction of unanswered queries. A compliant query-retention policy should be consistent, defensible, and auditable rather than dependent on whether the physician provided a response or whether the query affected billing.
Organizations may structure query retention differently depending on legal requirements, health-record policy, technology, and organizational governance. Queries may be part of the permanent health record or retained as another retrievable business record, depending on policy. The key point is that disposition should not be manipulated to hide unanswered or inconvenient clarification activity.
Destroying unresolved queries can impair auditability, create an appearance that the organization is selectively preserving only favorable documentation activity, and undermine the integrity of the CDI process.
The 2026 ACDIS/AHIMA guidelines are the current foundational standard for query-practice design and supersede prior versions.
A query need not automatically remain in the permanent medical record forever; retention requirements depend on applicable organizational and legal policies. What is unacceptable is an inconsistent approach designed to remove evidence based on outcome.
CCDS Reference Topics: Query retention; compliance; auditability; organizational policy; documentation integrity.
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NEW QUESTION # 31
A CDI manager notes that the physician query response rate is 98%, but only 55% of queries are answered before discharge. Which metric should receive the MOST immediate workflow analysis?
Answer: A
Explanation:
The overall response rate is excellent at 98%, but the fact that only 55% of queries are resolved before discharge indicates a meaningful concurrent-workflow issue.
Concurrent CDI is most effective when clarification occurs while the patient remains hospitalized and the physician has immediate access to the clinical context. Delayed responses can contribute to retrospective work, final-bill holds, coding delays, and administrative escalation.
The CDI manager should determine whether delays cluster by provider, specialty, query type, unit, day of week, discharge timing, or electronic-query process. Other factors may include insufficient notification, physician workflow, poor escalation protocols, or queries being issued too late in the stay.
CMI and MCC volume do not directly measure response timeliness and should not substitute for analysis of the actual operational problem.
Importantly, programs should not pressure physicians into rapid but clinically superficial responses. Query timing initiatives must preserve thoughtful provider judgment and compliant communication.
ACDIS identifies medical-record review, communication, query technique, and data-mining/reporting functions among core CCDS competencies.
CCDS Reference Topics: Query timeliness; concurrent CDI; physician engagement; workflow analysis; program metrics.
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NEW QUESTION # 32
A patient with sepsis has acute confusion, impaired attention, fluctuating mental status, and no focal neurologic findings. CT of the head is negative. The provider documents only "AMS secondary to infection." Which clarification would be MOST clinically appropriate?
Answer: A
Explanation:
The documented acute mental-status change associated with systemic infection creates a reasonable clarification opportunity for acute metabolic encephalopathy, assuming the complete clinical record supports that diagnosis.
Encephalopathy represents diffuse cerebral dysfunction arising from systemic, metabolic, toxic, hypoxic, infectious, or other causes. Acute confusion, impaired attention, fluctuating cognition, and absence of a focal lesion can support an encephalopathic process.
However, the CDI specialist cannot convert "altered mental status" into encephalopathy independently. The provider must determine whether the patient's presentation represents metabolic encephalopathy, delirium, medication effect, dementia, another neurologic condition, or simply a nonspecific symptom.
Chronic dementia does not fit the acute fluctuating pattern unless underlying dementia is separately documented. Cerebral infarction would generally require compatible focal neurologic findings and clinical or imaging evidence. Transient global amnesia typically presents with prominent acute memory disturbance rather than generalized encephalopathy.
A compliant query should include the mental-status findings, infectious process, relevant laboratory data, neurologic evaluation, treatment, and clinical course.
CCDS Reference Topics: Encephalopathy; altered mental status; infection; neurologic clinical indicators; diagnostic clarification.
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NEW QUESTION # 33
A patient's record contains fever, tachycardia, hypotension, positive blood cultures, and treatment with IV antibiotics and fluids. No corresponding diagnosis has been documented. Which query format is MOST appropriate?
Answer: C
Explanation:
A neutral multiple-choice query is appropriate when significant clinical indicators exist but no corresponding diagnosis has been documented. The query should present the relevant patient-specific facts and allow the provider to exercise independent clinical judgment among reasonable alternatives.
For example, depending on the complete record, options could include sepsis, localized infection without sepsis, bacteremia, another condition, or unable to determine. Each offered diagnosis must be clinically supported.
A yes/no query is generally inappropriate when it introduces a completely new diagnosis that has never appeared in the health record. Option B is overtly leading because it directs the provider to document sepsis rather than requesting clarification.
The 2026 ACDIS/AHIMA compliant-query guidance, published August 20, 2026, supersedes all previous versions and serves as the current foundational standard for CDI and coding query practice. It applies across inpatient, outpatient, ambulatory, and professional-fee settings.
The purpose of the query is documentation integrity-not obtaining an MCC, changing the MS-DRG, or achieving a particular quality result.
CCDS Reference Topics: Multiple-choice queries; missing diagnosis; nonleading queries; clinical indicators; compliance.
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NEW QUESTION # 34
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