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| Section | Weight | Objectives |
|---|---|---|
| Anatomy and physiology, pathophysiology, pharmacology, and medical terminology | 19.17% | - Clinical conditions and clinical indicators - Anatomy, physiology, pathophysiology, pharmacology, and terminology |
| Official Guidelines for Coding and Reporting | 14.17% | - Principal and secondary diagnosis assignment - Coding guidelines, AHA Coding Clinic, HACs, and POA indicators |
| Medical record documentation | 19.17% | - Documentation clarification and compliant physician queries - Documentation requirements and diagnosis or procedure code assignment |
| Impact of reportable diagnoses on quality of care | 8.33% | - Mortality, severity of illness, and risk of mortality - Quality metrics, reporting programs, and financial impact |
| Healthcare regulations, reimbursement, and documentation requirements related to the IPPS | 12.5% | - IPPS, MS-DRGs, reimbursement, and medical necessity - CC/MCC, CMI, Medicare contractors, and compliance |
| Communication skills | 9.17% | - Physician education and effective communication - CDI and coding roles and interdisciplinary collaboration |
| Professionalism, ethics, and compliance | 9.17% | - Query compliance, DRG creep, and audit risks - Confidentiality, DRG compliance, and ethical CDI practices |
| Healthcare facility CDI program analysis | 8.33% | - Data analysis, forecasting, and performance measurement - CDI productivity, provider response, CMI, and program metrics |
人々は異なる目標がありますが、我々はあなたにACDISのCCDS試験に合格させるという同じ目標があります。この目標を達成するのは、あなたにとってIT分野での第一歩だけですが、我々のACDISのCCDSソフトを開発するすべての意義です。だから、我々は尽力して我々の問題集を多くしてJPTestKingの専門かたちに研究させてあなたの合格する可能性を増大します。あなたの利用するACDISのCCDSソフトが最新版のを保証するために、一年間の無料更新を提供します。
質問 # 82
A physician documents obesity. A registered dietitian records a BMI of 38.4 kg/m². Which statement is MOST accurate?
正解：D
解説：
BMI is one of the recognized ICD-10-CM non-provider documentation exceptions. A qualified clinician such as a registered dietitian may document the BMI value, while the associated diagnosis-such as overweight or obesity-must be appropriately documented by the responsible provider.
Therefore, the coder may use the documented BMI of 38.4 in conjunction with the provider's obesity diagnosis when reporting requirements are otherwise satisfied.
The BMI itself does not permit the coder or CDI specialist to independently diagnose obesity or determine obesity type. Clinical diagnosis remains the provider's responsibility.
This distinction prevents unnecessary physician queries merely to reproduce objective measurements that have already been reliably documented by another qualified clinician.
Comparable non-provider documentation exceptions include pressure-ulcer stage and certain standardized scales or clinical details under applicable ICD-10-CM guidance.
CDI specialists should know these exceptions because unnecessary queries increase provider burden and can delay coding without improving data quality. Conversely, they should not extend the exception beyond what ICD-10-CM permits.
CCDS Reference Topics: BMI; obesity; non-provider documentation; dietitian documentation; coding exceptions.
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質問 # 83
A CDI team identifies that orthopedic surgeons frequently document "postoperative anemia" without specifying whether blood loss is acute, expected, chronic, or clinically insignificant. What is the BEST educational strategy?
正解：A
解説：
The strongest educational approach is targeted specialty-specific education using the surgeons' own documentation trends and realistic clinical examples. This addresses the recurring documentation problem while remaining clinically relevant to the audience.
Orthopedic surgeons do not need to become coding specialists. Education should instead explain which clinical distinctions matter-for example, whether anemia represents expected postoperative change, acute blood loss anemia, chronic anemia, or another diagnosis-and why accurate terminology improves the medical record.
Providing a long code list is unlikely to improve physician documentation behavior. Instructing surgeons to document acute blood loss anemia whenever hemoglobin decreases would be clinically inappropriate and could produce unsupported diagnoses. A postoperative hemoglobin decline may reflect hemodilution, expected surgical blood loss, chronic anemia, or other factors.
Stopping queries would leave meaningful ambiguities unresolved.
ACDIS/AHIMA query guidance emphasizes documentation accuracy and provider independence rather than reimbursement-focused diagnosis selection.
Successful physician education should be concise, clinically oriented, supported by service-line data, and reinforced when subsequent query trends demonstrate persistent problems.
CCDS Reference Topics: Physician education; communication; postoperative anemia; query trends; provider engagement.
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質問 # 84
A CDI specialist's working MS-DRG differs from the final coder-assigned MS-DRG in 18% of reviewed cases. What is the BEST initial management response?
正解：B
解説：
A significant mismatch rate should trigger structured CDI/coding reconciliation, not an assumption that either department is wrong.
Working MS-DRGs are provisional. Final coding may change because of discharge-summary diagnoses, operative reports, pathology results, late physician clarification, Coding Clinic guidance, sequencing conventions, final procedure coding, CC/MCC exclusions, or other grouper logic unavailable during the concurrent CDI review.
The manager should categorize mismatch causes. Useful categories include principal-diagnosis differences, missed secondary diagnoses, procedure-code differences, coding-guideline interpretation, query results, discharge documentation, and technical grouper issues.
Patterns can then identify whether education is needed for CDI specialists, coding professionals, physicians, or multiple groups.
Requiring coding staff to adopt the CDI working DRG would undermine coding independence and final coding accountability. Excluding mismatches from metrics would conceal an important quality indicator.
CMS confirms that the FY 2026 MS-DRG Definitions Manual contains the complete grouper logic for Version 43.1, making current grouper rules essential when evaluating discrepancies.
CCDS Reference Topics: MS-DRG reconciliation; CDI/coder agreement; program analysis; education; grouper logic.
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質問 # 85
A patient is admitted with a documented diagnosis of acute hypoxic respiratory failure. Which of the following clinical data BEST supports the diagnosis?
正解：D
解説：
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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質問 # 86
After a month of intermittent antibiotic use, the patient is admitted. An infectious-control physician documents a diagnosis of Clostridium difficile in the inpatient medical record. Which domain of the MOST current Hospital Value-Based Purchasing program would this diagnosis impact?
正解：C
解説：
The relevant Hospital Value-Based Purchasing domain is the Safety domain, corresponding most closely to option D. CMS's FY 2026 Hospital VBP program maintains a Safety domain that includes healthcare- associated infection performance measures, including C. difficile infection. CMS's current VBP Safety dataset specifically identifies C. difficile among its healthcare-associated infection measures.
It is important to distinguish the domain from an individual measure. "Hospital-acquired infection" describes the type of quality measure, but the formal broader scoring domain is Safety. PSI 90 is also associated with patient safety measurement, but it is not the name of the overall VBP domain.
From a CDI standpoint, documentation accuracy matters because coded and quality-reporting data can influence organizational performance assessment. However, documentation of C. difficile alone does not automatically establish that an infection qualifies as a hospital-onset event for every quality program. Timing and the applicable measure specifications determine whether an individual episode enters a particular healthcare-associated infection metric.
Therefore, CDI professionals should accurately capture the infection and its clinical circumstances without attempting to classify an event as hospital acquired solely to influence quality scores.
CCDS Reference Topics: Hospital VBP; Safety domain; healthcare-associated infections; C. difficile; quality reporting.
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質問 # 87
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