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| Section | Weight | Objectives |
|---|---|---|
| Communication skills | 9.17% | - Physician education and effective communication - CDI and coding roles and interdisciplinary collaboration |
| Healthcare facility CDI program analysis | 8.33% | - Data analysis, forecasting, and performance measurement - CDI productivity, provider response, CMI, and program metrics |
| Professionalism, ethics, and compliance | 9.17% | - Confidentiality, DRG compliance, and ethical CDI practices - Query compliance, DRG creep, and audit risks |
| Healthcare regulations, reimbursement, and documentation requirements related to the IPPS | 12.5% | - CC/MCC, CMI, Medicare contractors, and compliance - IPPS, MS-DRGs, reimbursement, and medical necessity |
| 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 |
| 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 |
| Anatomy and physiology, pathophysiology, pharmacology, and medical terminology | 19.17% | - Clinical conditions and clinical indicators - Anatomy, physiology, pathophysiology, pharmacology, and terminology |
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NEW QUESTION # 62
A patient's record contains fever, tachycardia, hypotension, positive blood cultures, and treatment with IV antibiotics and fluids. No corresponding diagnosis has been documented. Which query format is MOST appropriate?
Answer: C
Explanation:
A neutral multiple-choice query is appropriate when significant clinical indicators exist but no corresponding diagnosis has been documented. The query should present the relevant patient-specific facts and allow the provider to exercise independent clinical judgment among reasonable alternatives.
For example, depending on the complete record, options could include sepsis, localized infection without sepsis, bacteremia, another condition, or unable to determine. Each offered diagnosis must be clinically supported.
A yes/no query is generally inappropriate when it introduces a completely new diagnosis that has never appeared in the health record. Option B is overtly leading because it directs the provider to document sepsis rather than requesting clarification.
The 2026 ACDIS/AHIMA compliant-query guidance, published August 20, 2026, supersedes all previous versions and serves as the current foundational standard for CDI and coding query practice. It applies across inpatient, outpatient, ambulatory, and professional-fee settings.
The purpose of the query is documentation integrity-not obtaining an MCC, changing the MS-DRG, or achieving a particular quality result.
CCDS Reference Topics: Multiple-choice queries; missing diagnosis; nonleading queries; clinical indicators; compliance.
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NEW QUESTION # 63
A patient with an indwelling central venous catheter develops fever and positive blood cultures for Staphylococcus aureus. The physician documents "bacteremia" but does not establish whether the catheter caused the infection. Which action is MOST appropriate?
Answer: D
Explanation:
The record supports a cause-and-effect clarification query. The presence of an indwelling central line together with bacteremia does not automatically establish a catheter-related bloodstream infection or device complication.
The provider must determine whether the infection is related to the catheter, another source, or an undetermined cause when the classification requires clinical linkage. CDI should present the catheter history, onset of fever, culture results, line assessment, treatment, line removal or exchange if applicable, and other relevant findings without directing the provider toward a device-related complication.
A positive blood culture likewise does not independently establish sepsis. Bacteremia and sepsis are distinct concepts; the provider must make the systemic infection diagnosis using the entire clinical picture.
Automatically assigning a complication merely because a device is present risks inaccurate reporting of healthcare-associated complications and may affect quality metrics, reimbursement, and public data.
Current ACDIS/AHIMA guidance emphasizes that queries should arise from patient-specific clinical information and preserve provider clinical judgment rather than presuming causal relationships.
CCDS Reference Topics: Device-related infections; cause-and-effect relationships; bacteremia; clinical indicators; compliant query construction.
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NEW QUESTION # 64
Which of the following programs specifically reduces applicable Medicare payments by 1% for hospitals in the worst-performing quartile based on hospital-acquired-condition measures?
Answer: A
Explanation:
The Hospital-Acquired Condition Reduction Program (HACRP) imposes a 1% reduction in applicable Medicare fee-for-service payments on subsection (d) hospitals ranking in the worst-performing quartile based on the Total HAC Score.
For the current program, CMS uses six measures: the CMS Patient Safety and Adverse Events Composite (PSI 90) and five healthcare-associated infection measures-CLABSI, CAUTI, specified surgical-site infection, MRSA bacteremia, and C. difficile infection.
HACRP must be distinguished from the separate DRA Hospital-Acquired Condition/Present-on-Admission payment provision. CMS explicitly states that these are different programs.
Hospital Value-Based Purchasing also links quality performance with hospital payment, but its structure is different: it is funded through a 2% reduction of participating hospitals' base operating DRG payments that is redistributed through value-based incentives.
For CDI professionals, accurate clinical documentation helps ensure that quality data appropriately represent the patient's condition and hospital course. CDI should not attempt to suppress valid complications or create unsupported comorbidities to change quality performance.
CCDS Reference Topics: HACRP; PSI 90; HAIs; quality reimbursement; CMS quality programs.
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NEW QUESTION # 65
A patient's past medical history lists remote peptic ulcer disease. During the current admission, the condition receives no evaluation, treatment, diagnostic workup, extended length of stay, or increased nursing monitoring. Which statement is MOST accurate?
Answer: D
Explanation:
The remote peptic ulcer disease generally does not meet the definition of a reportable secondary diagnosis for this hospitalization because it does not affect current patient care.
For inpatient reporting, additional diagnoses include clinically significant conditions that coexist at admission or develop subsequently and affect care through factors such as clinical evaluation, therapeutic treatment, diagnostic procedures, extended length of stay, or increased nursing care and monitoring.
Merely appearing in a past medical history or problem list does not make a condition reportable. The condition must satisfy applicable secondary-diagnosis criteria or another specific coding instruction.
This principle prevents the coded record from becoming populated with historical conditions having no relevance to the current hospitalization. It also underscores why CDI review should focus on diagnoses that meaningfully characterize the current episode of care.
Whether a diagnosis is classified as a CC or MCC is a separate MS-DRG concept. A diagnosis must first be appropriately reportable before its severity classification becomes relevant.
The CCDS outline specifically requires application of both principal- and secondary-diagnosis reporting principles.
CCDS Reference Topics: Additional diagnoses; clinically significant secondary conditions; historical diagnoses; resource utilization.
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NEW QUESTION # 66
Which of the following diagnoses is classified as a major complication/comorbidity (MCC) under the FY
2026 MS-DRG system?
Answer: B
Explanation:
Severe protein-calorie malnutrition is the correct answer. This question is adapted from an official CCDS sample question published by ACDIS.
Under the FY 2026 MS-DRG Definitions Manual, E43, unspecified severe protein-calorie malnutrition, is classified as an MCC. In contrast, moderate and mild protein-calorie malnutrition codes are classified as CCs rather than MCCs.
An MCC can materially affect MS-DRG assignment when the applicable DRG family differentiates cases by MCC status and when no exclusion or other grouper rule prevents the effect. However, the financial effect is never sufficient justification for a query. Documentation must be clinically supported and reflect the patient's actual condition.
A dietitian may document detailed nutrition findings and malnutrition criteria, but the reportable diagnosis ordinarily requires documentation by the provider responsible for establishing diagnoses. Therefore, when strong nutritional indicators exist but the provider has not documented malnutrition, a compliant query may be appropriate.
For CCDS preparation, candidates should understand both the clinical characteristics of malnutrition and its coding/reimbursement classification.
CCDS Reference Topics: MCCs; malnutrition; MS-DRG methodology; documentation requirements; IPPS.
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NEW QUESTION # 67
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