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| Section | Weight | Objectives |
|---|---|---|
| Topic 1: Clinical Knowledge & Disease Processes Application | 20% | - Medical terminology, anatomy, physiology, pathophysiology - Clinical indicators, lab results, medications, diagnostic findings - Disease processes across body systems applied to chart review |
| Topic 2: Quality, Risk Adjustment & Health Initiatives | 15% | - Quality reporting, public reporting, and compliance programs - Severity of Illness (SOI) / Risk of Mortality (ROM) - Risk adjustment models and documentation impact |
| Topic 3: Coding Guidelines & Official Reporting Standards | 15% | - AHIMA/ACDIS Guidelines for Compliant Query Practice - ICD-10-CM/PCS Official Guidelines for Coding and Reporting - Coding integrity and compliant documentation practices |
| Topic 4: Clinical Documentation Review & Query Practices | 20% | - Documentation gap identification and resolution - Concurrent and retrospective chart review methodologies - Query development, communication, and ethical standards |
| Topic 5: Healthcare Regulations, Reimbursement & Documentation Requirements – IPPS | 15% | - Documentation responsibilities of medical and clinical staff - Medicare Severity Diagnostic Related Groups (MS-DRGs) - Inpatient Prospective Payment System (IPPS) fundamentals |
| Topic 6: CDI Program Management & Professional Practice | 15% | - Program metrics, benchmarks, and performance measurement - Provider education and training strategies - Ethics, HIPAA, and professional conduct |
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NEW QUESTION # 41
A hospital had 1,000 inpatient discharges during a reporting period. The sum of the MS-DRG relative weights for those discharges was 1,750. What is the hospital's case mix index (CMI)?
Answer: B
Explanation:
Case mix index is calculated by dividing the total MS-DRG relative weights by the number of discharges:
1,750 ÷ 1,000 = 1.75
Therefore, the hospital's CMI is 1.75.
CMI is an aggregate measure representing the average relative resource intensity of the hospital's inpatient population under the MS-DRG system. A higher CMI generally indicates that the hospital treated cases assigned to DRGs with higher average relative weights.
However, CMI should never be interpreted as a pure measure of clinical quality. It can be affected by patient population, service-line composition, surgical volume, transplant activity, documentation completeness, coding accuracy, changes in grouper methodology, and other factors.
CMS specifically publishes hospital CMI data and uses MS-DRG relative weights in the IPPS payment methodology. CMS also maintains FY 2026 case-mix and relative-weight files as part of the final-rule data package.
For CDI program analysis, unexplained CMI changes should trigger investigation rather than an automatic assumption of poor documentation. Service-line and diagnosis-level analysis usually provides a more meaningful interpretation.
CCDS Reference Topics: Case mix index; relative weights; CDI analytics; MS-DRGs; program performance.
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NEW QUESTION # 42
A 91-year-old has a past medical history of heart failure, COPD, and adenocarcinoma of the lung and brain.
The patient presents with shortness of breath, weakness, and pain. His vital signs are T 99°F, RR 18, BP 108
/74, and pulse 110. Pulse oximetry is 98% on 2 L nasal cannula. He is admitted with HCAP, COPD, and diastolic heart failure.
Initial laboratory values are:
Hgb: 9.0
Sodium: 134.0
WBC: 12.9
The physician orders antibiotics and 2 L nasal cannula. Based upon the information provided above, which of the following queries would be MOST appropriate?
Answer: C
Explanation:
The most appropriate clarification concerns the underlying cause/type of pneumonia. The record documents
"HCAP," but that term does not identify a specific causative organism or pathophysiologic pneumonia type.
The patient is being actively treated with antibiotics, has leukocytosis, and was admitted with pneumonia- related documentation, creating a legitimate opportunity to clarify clinically supported specificity.
The other options are weaker. Hemoglobin of 9.0 supports anemia but does not establish acute blood loss anemia without evidence of active/recent blood loss or an acute decline. Sodium of 134 mEq/L is only mildly reduced and, without treatment or other clinical significance, does not by itself justify seeking a diagnosis solely from the laboratory value.
The record already specifies diastolic heart failure. Although acuity could sometimes warrant clarification, the presented findings do not strongly establish acute decompensated heart failure: oxygen requirement is modest, saturation is 98%, and no pulmonary edema, diuretic escalation, or other acute HF indicators are provided.
The query should remain neutral and allow the provider to identify the pneumonia type only if clinically determinable.
CCDS Reference Topics: Pneumonia specificity; clinical indicators; documentation clarification; query prioritization.
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NEW QUESTION # 43
A patient is admitted with fever, productive cough, and hypotension. The attending physician documents sepsis due to pneumonia. Acute kidney injury develops and is documented as due to sepsis. Which of the following is the MOST appropriate sequencing concept?
Answer: D
Explanation:
When sepsis due to a localized infection is responsible for the admission, the systemic infection is generally sequenced first, followed by the localized infection. If acute organ dysfunction is documented as associated with the sepsis, severe sepsis coding additionally requires the appropriate R65.2- code and code(s) for the acute organ dysfunction.
The severe-sepsis code itself is not sequenced as principal diagnosis. The underlying systemic infection precedes it. In this case, the patient's AKI has specifically been linked to sepsis, supporting the severe-sepsis framework.
Pneumonia remains important because it identifies the localized source of infection, but it does not generally precede the systemic infection when sepsis is present on admission and is responsible for the hospitalization.
The CDI specialist should verify that the documentation clearly establishes the relationship between the acute organ dysfunction and sepsis. Organ dysfunction occurring in a patient with sepsis is not automatically attributable to sepsis when another cause is documented or clinically plausible.
The FY 2026 ICD-10-CM Official Guidelines govern these sequencing principles.
CCDS Reference Topics: Sepsis; severe sepsis; principal diagnosis; acute organ dysfunction; sequencing.
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NEW QUESTION # 44
A patient underwent open small bowel resection with anastomosis for colon cancer. The physician notes,
"Post-op ileus, awaiting return of bowel function." Which of the following actions should a CDI specialist take FIRST?
Answer: C
Explanation:
The phrase "post-op ileus" establishes that the ileus occurred after surgery, but it does not necessarily establish that the ileus represents a reportable surgical complication rather than an expected transient consequence of abdominal surgery. The relationship and clinical significance therefore require clarification.
ICD-10-CM guidance on complications of care states that not every condition occurring during or following surgery is automatically classified as a complication. Code assignment depends on provider documentation establishing the relationship between the condition and the care or procedure, and the documentation must support clinical significance. When that relationship is unclear, the provider should be queried.
Assigning a complication code immediately would therefore be premature. Likewise, simply coding postoperative ileus without resolving whether it represents expected postoperative physiology or a clinically significant complication could misrepresent the episode.
Escalation to a physician advisor or CDI manager is unnecessary as the first action because this is a standard documentation-clarification issue that can be addressed directly through a compliant provider query.
CCDS Reference Topics: Official Guidelines-complications of care; medical record documentation; compliant provider clarification.
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NEW QUESTION # 45
The attending physician documents acute respiratory failure. The patient has normal respiratory effort, oxygen saturation of 97% on room air, no supplemental oxygen requirement, and no ventilatory support. What is the MOST appropriate CDI action?
Answer: B
Explanation:
This is a classic clinical validation query scenario. A diagnosis has been documented, but the available clinical evidence appears inconsistent with or insufficient to support that diagnosis.
The CDI specialist should not independently delete acute respiratory failure, substitute another diagnosis, or direct coding personnel to disregard provider documentation without an appropriate clarification process.
Instead, the query should objectively present the relevant clinical findings-normal respiratory effort, room- air oxygenation, absence of escalating oxygen requirements, and absence of ventilatory support-and ask the provider to clarify the diagnosis.
The provider may confirm respiratory failure and document additional clinical reasoning, revise the diagnosis, identify another condition, or state that the diagnosis was ruled out. The CDI specialist's responsibility is to support record integrity, not to replace provider clinical judgment.
The official CCDS content outline specifically requires candidates to understand mechanisms for addressing diagnoses lacking clinical support and to distinguish compliant from noncompliant queries. The current 2026 ACDIS/AHIMA guidance is the foundational query-practice standard.
CCDS Reference Topics: Clinical validation; respiratory failure; unsupported diagnoses; compliant query practice; documentation integrity.
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NEW QUESTION # 46
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