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| Section | Weight | Objectives |
|---|---|---|
| Healthcare facility CDI program analysis | 8.33% | - High-frequency DRGs - Basic computer and software application skills - Publicly reported data - Physician performance measurement - Provider response rates - CC/MCC capture - CDI specialist productivity metrics - Tracking and trending physician, department, and hospital performance - Case mix index (CMI) - PEPPER data - Hospital Value-Based Purchasing measures - Severity of illness and risk of mortality - CDI program forecasting - Hospital-specific financial data - Patient Safety Indicators |
| Medical record documentation | 19.17% | - When a physician query is warranted - Physician query formats - Addressing diagnoses without clinical support - Clinical indicators - Types of physician queries - Situations in which queries are not appropriate - Translating clinical indicators into compliant queries - Health record elements used for diagnosis and procedure code assignment - Documentation requiring clarification - Provider role and diagnosis code assignment - ACDIS/AHIMA Guidelines for Achieving a Compliant Query Practice - Compliant and noncompliant queries |
| Professionalism, ethics, and compliance | 9.17% | - Compliance risks indicated by PEPPER - Potential DRG creep - Leading queries - Medical record confidentiality - DRG compliance initiatives - CDI department goals beyond reimbursement |
| 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 - Endocrine, nutritional, and metabolic diseases and disorders - Pharmaceuticals and disease processes - Standard medical abbreviations - Diseases and disorders of the kidney and urinary tract - Diseases and disorders of the circulatory system - Diseases and disorders of the digestive system - Infectious and parasitic diseases - Clinical indicators and query opportunities by Major Diagnostic Category - HIV infections - Diseases and disorders of the nervous system - Mental diseases and disorders - Diseases and disorders of the blood and blood-forming organs and immunological disorders - Alcohol/drug use and alcohol/drug-induced organic brain disorders - Diseases and disorders of the hepatobiliary system - Diagnostic tests as clinical indicators - Diseases and disorders of the musculoskeletal system - Myeloproliferative diseases and disorders and poorly differentiated neoplasms - Diseases and disorders of the respiratory system |
| Communication skills | 9.17% | - Effective and non-confrontational physician communication - Roles and responsibilities of CDI specialists - Reconciling CDI working DRGs with final coded DRGs - Physician education forms and tools - Educational presentations for healthcare departments and administration - Verbal versus written physician communication - Roles and responsibilities of coders working with CDI departments |
| 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 - Hospital Value-Based Purchasing - Hospital-Acquired Condition Reduction Program - Documentation and code assignment impact on mortality index - Hospital Inpatient Quality Reporting Program - CDI impact on Hospital Value-Based Purchasing - Coded data elements affecting Patient Safety Indicators - Mortality reviews and observed/expected ratios - Hospital Readmissions Reduction Program - Patient Safety Indicators |
| Healthcare regulations, reimbursement, and documentation requirements related to the IPPS | 12.5% | - Medical staff and clinical staff documentation responsibilities - Medicare contractors and their impact on CDI - Medicare Severity Diagnosis Related Groups (MS-DRGs) - Major complication/comorbidity (MCC) - Documentation and medical necessity of setting - Principal diagnosis and medical necessity - Case mix index (CMI) - Coding and billing practices vulnerable to denial - Documentation impact on IPPS reimbursement - Inpatient admission criteria and CMS Two-Midnight Rule - IPPS and its updates and revisions - Complication/comorbidity (CC) |
| Official Guidelines for Coding and Reporting | 14.17% | - Secondary diagnosis assignment - Principal diagnosis assignment - Hospital-acquired conditions - Coding guidelines for principal diagnosis selection - Official Guidelines for Coding and Reporting updates - AHA Coding Clinic - Discharge dispositions and transfers - Working DRG assignment for multiple diagnoses - Present on admission indicators |
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NEW QUESTION # 127
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 # 128
Under the Hospital Readmissions Reduction Program, what is the maximum payment reduction applicable to an eligible hospital?
Answer: D
Explanation:
The maximum payment reduction under the Hospital Readmissions Reduction Program is 3%. CMS expresses this through a payment adjustment factor ranging from 1.0, indicating no reduction, to 0.97, representing the maximum 3% reduction.
The HRRP links Medicare payment to excess readmission performance for specified clinical populations.
CMS applies the resulting adjustment to applicable Medicare fee-for-service base operating DRG payments.
This program should not be confused with other Medicare hospital quality-payment initiatives. The HAC Reduction Program imposes a 1% reduction on hospitals in the worst-performing quartile, while Hospital Value-Based Purchasing uses a 2% reduction-and-redistribution mechanism.
CMS's FY 2026 IPPS final rule also finalized changes to HRRP methodology that begin with the FY 2027 program year, including incorporation of Medicare Advantage data into the six readmission measures and shortening the applicable performance period from three years to two.
For CDI, the central obligation remains ensuring that the clinical record accurately portrays patient severity, conditions treated, discharge circumstances, and comorbid disease burden.
CCDS Reference Topics: HRRP; readmission measures; quality reimbursement; payment adjustments; risk adjustment.
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NEW QUESTION # 129
A registered dietitian documents severe malnutrition based on substantial weight loss, severe muscle depletion, and prolonged inadequate energy intake. The attending physician documents only "poor oral intake." What is the BEST action for the CDI specialist?
Answer: A
Explanation:
The appropriate action is to query the provider regarding the patient's nutritional diagnosis. The dietitian's assessment supplies important clinical evidence, but the associated diagnosis of malnutrition generally must be documented by an appropriate provider before the diagnosis code is assigned.
The FY 2026 ICD-10-CM Official Guidelines permit selected elements to come from non-provider clinicians-such as BMI, pressure-ulcer stage, coma scale, NIH Stroke Scale, certain social determinants, and other specifically identified exceptions. Malnutrition diagnosis itself is not simply assigned solely from a dietitian's diagnostic statement under this general rule.
Ignoring the dietitian's findings would also be inappropriate. CDI review should integrate multidisciplinary documentation because such documentation can reveal valid clarification opportunities. Severe weight loss, reduced intake, and documented muscle depletion provide a clinical basis for a neutral query.
The query should not state that severe malnutrition "must" be documented because it is an MCC. Instead, it should present the relevant nutrition findings and allow the provider to determine the diagnosis, including severe malnutrition, another level of malnutrition, another cause, or inability to determine.
CCDS Reference Topics: Malnutrition; multidisciplinary documentation; provider diagnosis requirements; clinical indicators.
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NEW QUESTION # 130
A patient develops chest pain and elevated troponins while receiving care in the emergency department. The physician diagnoses an NSTEMI. Several hours later, an inpatient admission order is written. How should the NSTEMI generally be considered for POA purposes?
Answer: C
Explanation:
For POA reporting, "present on admission" refers to a condition present at the time the order for inpatient admission occurs. Conditions that develop during an outpatient encounter-including emergency-department, observation, or outpatient surgery care-before the inpatient admission order are generally considered POA when they are present at that inpatient admission point.
Therefore, the NSTEMI in this scenario is considered present on admission even though it developed after the patient physically arrived at the hospital.
This distinction is essential because hospital arrival and inpatient admission are not synonymous for POA purposes. A patient may spend hours in the ED or observation status before an inpatient order is entered.
The POA indicator applies to applicable principal and secondary diagnoses and is important to CMS's HAC payment provisions as well as quality analysis. A condition does not become hospital acquired merely because it arose somewhere on hospital premises before inpatient status began.
CDI specialists should clarify timing when the record does not establish whether a diagnosis existed before or after the inpatient admission order rather than relying solely on note timestamps or physical location.
The FY 2026 ICD-10-CM Official Guidelines contain the governing POA definitions and reporting rules.
CCDS Reference Topics: POA; emergency department; observation; timing of diagnosis; HAC payment logic.
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NEW QUESTION # 131
A hospital's case is assigned to an MS-DRG with a relative weight of 2.0000. What does the relative weight primarily indicate?
Answer: D
Explanation:
An MS-DRG relative weight represents relative expected resource consumption, not a direct severity score or mortality probability. Therefore, a relative weight of approximately 2.0 means the MS-DRG is associated with roughly twice the resource intensity of the average case represented by the standardized reference point.
CMS calculates and recalibrates MS-DRG relative weights using national hospital data as part of IPPS rate setting. The FY 2026 final-rule materials include the MS-DRG weighting factors as well as supporting cost data used in the relative-weight methodology.
Clinically complex cases often consume more resources, so relative weight may correlate with severity.
However, it is not equivalent to a patient's severity-of-illness score or risk-of-mortality score. Likewise, hospitals do not simply multiply their billed charges based on the DRG weight. IPPS payment involves the standardized amount plus various adjustments, including wage index and other applicable payment factors.
For CDI, accurate documentation matters because diagnoses and procedures drive MS-DRG assignment, and the assigned MS-DRG carries its specific relative weight.
CCDS Reference Topics: IPPS; MS-DRG relative weight; resource consumption; reimbursement methodology.
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NEW QUESTION # 132
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