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| Section | Weight | Objectives |
|---|---|---|
| Topic 1: 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 |
| Topic 2: Medical record documentation | 19.17% | - Documentation clarification and compliant physician queries - Documentation requirements and diagnosis or procedure code assignment |
| Topic 3: Healthcare facility CDI program analysis | 8.33% | - CDI productivity, provider response, CMI, and program metrics - Data analysis, forecasting, and performance measurement |
| Topic 4: Professionalism, ethics, and compliance | 9.17% | - Query compliance, DRG creep, and audit risks - Confidentiality, DRG compliance, and ethical CDI practices |
| Topic 5: 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 |
| Topic 6: Anatomy and physiology, pathophysiology, pharmacology, and medical terminology | 19.17% | - Anatomy, physiology, pathophysiology, pharmacology, and terminology - Clinical conditions and clinical indicators |
| Topic 7: Communication skills | 9.17% | - CDI and coding roles and interdisciplinary collaboration - Physician education and effective communication |
| Topic 8: Official Guidelines for Coding and Reporting | 14.17% | - Coding guidelines, AHA Coding Clinic, HACs, and POA indicators - Principal and secondary diagnosis assignment |
CCDS試験に向けて勉強しているときは、家族のためなど、仕事に行くのに忙しいかもしれません。誰もが効率的な仕事をするための時間は貴重です。優れたCCDS準備ガイドを取得したい場合、合格するまでの時間を短縮する必要があります。キーポイントと最新情報を選択して、CCDSガイドトレントを完成させています。練習するのに20時間から30時間しかかかりません。効果的な練習の後、CCDS試験トレントから試験ポイントを習得できます。その後、CCDS試験に合格するのに十分な自信があります。
質問 # 126
A patient with active breast cancer is admitted solely to receive a scheduled cycle of antineoplastic chemotherapy. No complication or acute disease process is responsible for the admission. Which diagnosis is generally sequenced first?
正解：B
解説：
When an inpatient encounter is solely for administration of chemotherapy, the encounter-for-chemotherapy code is generally sequenced first, followed by the code identifying the malignancy being treated.
This represents an important exception to the usual expectation that the underlying disease is the principal diagnosis. The circumstances of admission are specifically treatment administration rather than management of an acute complication of the malignancy.
If, however, the patient were admitted because of a complication-such as chemotherapy-induced neutropenic fever, dehydration, anemia, or another adverse effect-the principal-diagnosis analysis would follow the applicable guideline for that condition rather than automatically using the chemotherapy encounter code.
Similarly, if chemotherapy were administered incidentally during a hospitalization principally required for another condition, the encounter-for-chemotherapy code would not displace the actual principal diagnosis.
CDI professionals should therefore distinguish planned treatment encounters from admissions caused by complications of treatment or malignancy.
Clear documentation regarding the reason for admission, cancer site, treatment intent, metastatic disease, and complications helps support proper sequencing and accurate oncology data.
CCDS Reference Topics: Antineoplastic chemotherapy; encounter codes; neoplasm sequencing; principal diagnosis; oncology documentation.
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質問 # 127
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?
正解：B
解説：
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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質問 # 128
At discharge, the physician documents, "Possible gram-negative pneumonia." No later documentation rules out the condition. How should the diagnosis generally be handled for an inpatient admission?
正解：A
解説：
In the inpatient hospital setting, an uncertain diagnosis documented at discharge using terminology such as possible, probable, suspected, likely, questionable, compatible with, or consistent with may generally be coded as though the condition existed or was established.
Therefore, "possible gram-negative pneumonia" may be coded in accordance with the inpatient uncertain- diagnosis guideline when it remains the final diagnostic conclusion.
The rationale is that inpatient diagnostic evaluation and treatment frequently occur before absolute confirmation is available, and the patient may have been managed as though the suspected disease were present.
This rule is materially different from outpatient coding, where uncertain diagnoses are generally not coded as established and the documented signs, symptoms, or confirmed conditions are reported instead.
The presence of the uncertain terminology alone does not mandate a query. A query would be appropriate if documentation is contradictory, if the diagnosis is clinically unsupported, or if another documentation issue prevents correct code assignment.
CDI specialists need to recognize this inpatient-specific rule because unnecessary queries for "possible" or
"probable" diagnoses can create physician burden without improving coding accuracy.
CCDS Reference Topics: Uncertain inpatient diagnoses; discharge documentation; pneumonia; inpatient versus outpatient coding.
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質問 # 129
The physician evaluates a postoperative wound infection but states, "I cannot clinically determine whether the infection was already developing at admission or began after admission." Which POA indicator MOST accurately reflects this provider determination?
正解：B
解説：
POA indicator W means the provider is clinically unable to determine whether the condition was present on admission. That is precisely what is documented in this scenario.
This must be distinguished from POA indicator U. U means the documentation is insufficient to determine POA status, whereas W reflects an actual clinical determination that the timing cannot be established even after appropriate assessment.
Indicator Y means the condition was present when the inpatient admission order occurred, while N means it was not present at that point.
This distinction matters because POA status contributes to CMS Hospital-Acquired Condition payment logic and hospital quality analyses. CDI specialists should attempt to obtain clarification when timing is unclear, but they must accept a legitimate provider determination that onset cannot clinically be established.
Not every ambiguous timeline should be forced into either Y or N. When clinical evidence truly cannot resolve the timing, W is an appropriate reporting outcome.
CMS maintains separate annual POA-exempt resources and HAC/POA coding information for the applicable fiscal year.
CCDS Reference Topics: POA indicators; W versus U; onset timing; HACs; inpatient coding.
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質問 # 130
A patient with colon cancer is admitted solely for transfusion and management of anemia caused directly by the malignancy. No chemotherapy-related adverse effect is involved. Which condition is sequenced first?
正解：D
解説：
When the admission is for management of anemia associated directly with the malignancy, and treatment is directed only at the anemia, the malignancy is sequenced as principal diagnosis, followed by the appropriate anemia code.
The FY 2026 Official Guidelines specifically distinguish malignancy-associated anemia from anemia caused by chemotherapy. For anemia associated with the malignancy, the neoplasm is sequenced first. For anemia resulting from an adverse effect of chemotherapy or immunotherapy, the anemia code is sequenced first.
This distinction makes documentation of anemia etiology essential. Phrases such as "anemia in cancer patient" may not clearly establish whether anemia is attributable to malignancy, chemotherapy, bleeding, nutritional deficiency, chronic kidney disease, or another process.
An encounter code for transfusion does not replace the principal-diagnosis rules for an inpatient hospitalization when the underlying reason for treatment is established.
Likewise, weakness is a symptom and would not supersede the definitive documented cancer-related anemia.
CDI professionals should therefore look beyond the fact that transfusion occurred and identify whether the medical record clearly establishes the cause of the anemia.
CCDS Reference Topics: Neoplasm-related anemia; principal diagnosis; sequencing; chemotherapy versus malignancy; medical record specificity.
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質問 # 131
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1年以内にクライアントに無料アップデートを提供します。クライアントは、最新の業界動向を学び理解するために、より多くのCCDSガイド資料を入手できます。 CCDS実践ガイドの更新をタイムリーかつ定期的に担当する専門の専門家チームを強化します。彼らは、優れた公開著者の論文と業界内の最新の新しい知識ポイントを参照して、CCDSトレーニング資料を更新します。 1年後、クライアントは購入時に50％の割引を享受でき、古いクライアントは特定の割引を享受できます
CCDS日本語練習問題: https://www.jpntest.com/shiken/CCDS-mondaishu