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| Section | Weight | Objectives |
|---|---|---|
| Communication skills | 9.17% | - Roles and responsibilities of coders working with CDI departments - Physician education forms and tools - Roles and responsibilities of CDI specialists - Verbal versus written physician communication - Reconciling CDI working DRGs with final coded DRGs - Effective and non-confrontational physician communication - Educational presentations for healthcare departments and administration |
| Medical record documentation | 19.17% | - Situations in which queries are not appropriate - Types of physician queries - Addressing diagnoses without clinical support - Provider role and diagnosis code assignment - Health record elements used for diagnosis and procedure code assignment - Documentation requiring clarification - Physician query formats - Compliant and noncompliant queries - ACDIS/AHIMA Guidelines for Achieving a Compliant Query Practice - Translating clinical indicators into compliant queries - When a physician query is warranted - Clinical indicators |
| Professionalism, ethics, and compliance | 9.17% | - Compliance risks indicated by PEPPER - CDI department goals beyond reimbursement - DRG compliance initiatives - Leading queries - Potential DRG creep - Medical record confidentiality |
| Impact of reportable diagnoses on quality of care | 8.33% | - Coded data elements affecting Patient Safety Indicators - Hospital-Acquired Condition Reduction Program - 30-day mortality measures - Hospital Readmissions Reduction Program - Hospital Inpatient Quality Reporting Program - Mortality reviews and observed/expected ratios - Hospital Value-Based Purchasing - Healthcare-associated infections and complication codes - Patient Safety Indicators - Quality data from record abstraction and claims data - CDI impact on Hospital Value-Based Purchasing - Documentation and code assignment impact on mortality index |
| Anatomy and physiology, pathophysiology, pharmacology, and medical terminology | 19.17% | - Medications as clinical indicators - Pharmaceuticals and disease processes - Diseases and disorders of the respiratory system - Diseases and disorders of the digestive system - Clinical indicators and query opportunities by Major Diagnostic Category - HIV infections - Diagnostic tests as clinical indicators - Injuries, poisonings, and toxic effects of drugs - Myeloproliferative diseases and disorders and poorly differentiated neoplasms - Mental diseases and disorders - Diseases and disorders of the skin, subcutaneous tissue, and breast - Diseases and disorders of the nervous system - Standard medical abbreviations - Diseases and disorders of the kidney and urinary tract - Diseases and disorders of the circulatory system - Endocrine, nutritional, and metabolic diseases and disorders - Diseases and disorders of the hepatobiliary system - Infectious and parasitic diseases - Diseases and disorders of the blood and blood-forming organs and immunological disorders - Diseases and disorders of the musculoskeletal system - Alcohol/drug use and alcohol/drug-induced organic brain disorders |
| Healthcare facility CDI program analysis | 8.33% | - CC/MCC capture - Physician performance measurement - Basic computer and software application skills - Tracking and trending physician, department, and hospital performance - CDI program forecasting - Provider response rates - Case mix index (CMI) - Publicly reported data - PEPPER data - Patient Safety Indicators - CDI specialist productivity metrics - High-frequency DRGs - Hospital Value-Based Purchasing measures - Severity of illness and risk of mortality - Hospital-specific financial data |
| Healthcare regulations, reimbursement, and documentation requirements related to the IPPS | 12.5% | - Medicare contractors and their impact on CDI - Medical staff and clinical staff documentation responsibilities - 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 - Case mix index (CMI) - Principal diagnosis and medical necessity - Medicare Severity Diagnosis Related Groups (MS-DRGs) - Documentation and medical necessity of setting - Major complication/comorbidity (MCC) - Complication/comorbidity (CC) |
| Official Guidelines for Coding and Reporting | 14.17% | - Coding guidelines for principal diagnosis selection - AHA Coding Clinic - Official Guidelines for Coding and Reporting updates - Present on admission indicators - Principal diagnosis assignment - Discharge dispositions and transfers - Working DRG assignment for multiple diagnoses - Secondary diagnosis assignment - Hospital-acquired conditions |
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102. Frage
A patient presents with crushing substernal chest pain, diaphoresis, ST-segment depression, and a significant rise and fall in cardiac troponin. The cardiologist documents acute coronary syndrome but does not specify the final diagnosis. Which clarification is MOST clinically appropriate?
Antwort: A
Begründung:
The clinical picture presents an appropriate opportunity to clarify whether the patient has NSTEMI, unstable angina, or another acute coronary diagnosis.
A significant rise and/or fall in cardiac troponin consistent with acute myocardial injury, together with ischemic symptoms and ECG abnormalities, strongly raises concern for acute myocardial infarction. In contrast, unstable angina generally refers to ischemia without the biomarker evidence required for myocardial infarction.
Nevertheless, CDI should not make the diagnosis independently. Troponin elevations can occur in multiple conditions, including myocarditis, pulmonary embolism, sepsis, tachyarrhythmia, renal disease, and other forms of myocardial injury.
Therefore, the cardiologist should be asked to clarify the final diagnosis based on the complete clinical evaluation.
GERD, chronic stable angina, and old MI do not adequately reflect the acute findings described.
For CCDS preparation, cardiovascular questions frequently require distinguishing symptoms from established diagnoses and understanding the clinical indicators associated with NSTEMI, STEMI, type 2 MI, and other myocardial injury categories.
The ACDIS candidate handbook identifies anatomy, physiology, pharmacology, pathophysiology, and clinical record analysis as essential examination competencies.
CCDS Reference Topics: NSTEMI; acute coronary syndrome; troponin; myocardial ischemia; diagnostic clarification.
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103. Frage
A patient develops a surgical-site infection after abdominal surgery and is admitted with sepsis. The surgeon clearly documents "sepsis due to postoperative wound infection." Which diagnosis category is generally sequenced first?
Antwort: D
Begründung:
Sepsis resulting from a postprocedural infection follows specialized sequencing rules. The code identifying the postprocedural infection or surgical-site infection is sequenced first when applicable, followed by the code for sepsis following a procedure and any additional codes required for the infectious organism or severe sepsis.
The FY 2026 Official Guidelines specifically state that for sepsis following a postprocedural wound or surgical-site infection, the appropriate postprocedural infection code is sequenced first. An additional code for sepsis following a procedure is then assigned. If severe sepsis exists, the appropriate R65.2- code and codes for acute organ dysfunction are additionally reported.
This differs from ordinary sepsis due to a localized infection, where the systemic infection is typically sequenced before the localized infection when sepsis is the reason for admission.
The cause-and-effect relationship is also essential. A wound infection merely occurring after surgery does not automatically establish a postprocedural complication. Here, the surgeon has explicitly documented that relationship, so the necessary clinical linkage is present.
CCDS Reference Topics: Postprocedural infection; sepsis; surgical-site infection; complication coding; sequencing.
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104. Frage
Which of the following is considered by CMS to be a HAC requiring MS-DRG adjustment if not POA?
Antwort: C
Begründung:
CMS specifically includes deep vein thrombosis and pulmonary embolism following certain orthopedic procedures, including total knee replacement and hip replacement, among Hospital-Acquired Conditions subject to the HAC/POA payment provisions. Therefore, option C is correct.
Under the IPPS HAC payment policy, qualifying conditions that were not present on admission may lose their normal CC/MCC effect for MS-DRG assignment when all applicable criteria are met. This makes accurate POA determination essential in CDI and coding.
Pressure ulcers are also part of the HAC framework, but the CMS category historically applies specifically to Stage III and Stage IV pressure ulcers. An unstageable pressure ulcer does not automatically satisfy the Stage III/IV HAC category merely because it is severe or clinically significant. CMS materials distinguish an unstageable ulcer from a documented Stage III or IV ulcer.
Postoperative pneumonia and septic shock are not, by themselves, the specified HAC category represented by the answer choices.
The CCDS blueprint specifically requires candidates to identify CMS-designated HACs and understand the effect of POA assignment on payment.
CCDS Reference Topics: IPPS; Hospital-Acquired Conditions; POA; MS-DRG adjustment.
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105. Frage
Hospital A is developing a query policy. Open-ended queries will be encouraged. The provider is expected to document on the query form, which will be retained as part of the health record. Hospital A will remove any unanswered queries and shred them to avoid any incomplete forms within the health record. Which of the following is considered a high-risk query practice?
Antwort: B
Begründung:
The high-risk practice is destroying unanswered queries. Query retention should be governed by an established organizational policy and should not depend on whether the provider answers the query.
Selectively destroying unanswered queries can create significant compliance, audit, and record-integrity concerns because it removes evidence of the documentation-clarification process.
ACDIS/AHIMA guidance has consistently required organizations to establish query-retention policies.
Queries may be retained as part of the permanent health record or maintained as a retrievable business record according to organizational policy and legal requirements. The current 2026 ACDIS/AHIMA query practice guidance supersedes all previous editions, reinforcing the importance of a standardized, defensible query process.
Keeping queries in the health record is not inherently problematic when policy defines them as part of that record. Likewise, a new diagnosis may be included in a multiple-choice query when it is supported by patient- specific clinical indicators and the choices remain nonleading. A yes/no query can also be compliant in defined circumstances, such as clarification of a diagnosis or relationship already documented.
Selective destruction is therefore the clear compliance risk.
CCDS Reference Topics: Query retention; compliance; organizational query policy; audit integrity.
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106. Frage
A patient is admitted with a stage 3 sacral pressure ulcer. During hospitalization, the wound deteriorates and is documented as stage 4 at the same site. Which reporting approach is appropriate?
Antwort: D
Begründung:
When a pressure ulcer progresses to a higher stage during an inpatient stay, ICD-10-CM instructs reporting that preserves both its stage at admission and the highest stage reached during hospitalization.
Therefore, the stage 3 condition present at admission and subsequent progression to stage 4 must both be represented according to the applicable coding instructions.
This approach accurately portrays both the patient's baseline condition and deterioration after admission.
Reporting only stage 4 would lose important POA information, while reporting only stage 3 would fail to capture the subsequent clinical severity.
An unstageable pressure-ulcer code is not appropriate simply because the wound changed stages.
"Unstageable" has a specific clinical meaning-typically the true depth cannot be determined because the wound base is obscured by slough or eschar or another specified circumstance.
CDI review should ensure documentation includes wound location, stage, laterality when applicable, timing of progression, and relevant wound-care assessment. Qualified wound clinicians may provide pressure-ulcer staging information under applicable non-provider documentation rules.
CCDS Reference Topics: Pressure ulcers; progression; POA; wound staging; quality reporting.
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107. Frage
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