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| Section | Weight | Objectives |
|---|---|---|
| Anatomy and physiology, pathophysiology, pharmacology, and medical terminology | 19.17% | - Diseases and disorders of the respiratory system - Alcohol/drug use and alcohol/drug-induced organic brain disorders - Diseases and disorders of the hepatobiliary system - Infectious and parasitic diseases - Myeloproliferative diseases and disorders and poorly differentiated neoplasms - HIV infections - Endocrine, nutritional, and metabolic diseases and disorders - Diseases and disorders of the musculoskeletal system - Diagnostic tests as clinical indicators - Diseases and disorders of the digestive system - Standard medical abbreviations - Mental diseases and disorders - Diseases and disorders of the skin, subcutaneous tissue, and breast - Diseases and disorders of the blood and blood-forming organs and immunological disorders - Diseases and disorders of the nervous system - Medications as clinical indicators - Pharmaceuticals and disease processes - Diseases and disorders of the circulatory system - Diseases and disorders of the kidney and urinary tract - Clinical indicators and query opportunities by Major Diagnostic Category - Injuries, poisonings, and toxic effects of drugs |
| Impact of reportable diagnoses on quality of care | 8.33% | - Hospital Readmissions Reduction Program - Hospital Value-Based Purchasing - Healthcare-associated infections and complication codes - Patient Safety Indicators - Documentation and code assignment impact on mortality index - 30-day mortality measures - Mortality reviews and observed/expected ratios - Hospital Inpatient Quality Reporting Program - Quality data from record abstraction and claims data - Hospital-Acquired Condition Reduction Program - Coded data elements affecting Patient Safety Indicators - CDI impact on Hospital Value-Based Purchasing |
| Communication skills | 9.17% | - Roles and responsibilities of coders working with CDI departments - Roles and responsibilities of CDI specialists - Physician education forms and tools - Verbal versus written physician communication - Reconciling CDI working DRGs with final coded DRGs - Educational presentations for healthcare departments and administration - Effective and non-confrontational physician communication |
| Healthcare facility CDI program analysis | 8.33% | - Provider response rates - PEPPER data - Hospital Value-Based Purchasing measures - Basic computer and software application skills - Publicly reported data - Severity of illness and risk of mortality - Physician performance measurement - CC/MCC capture - Tracking and trending physician, department, and hospital performance - CDI program forecasting - Patient Safety Indicators - Case mix index (CMI) - CDI specialist productivity metrics - Hospital-specific financial data - High-frequency DRGs |
| Official Guidelines for Coding and Reporting | 14.17% | - Working DRG assignment for multiple diagnoses - Secondary diagnosis assignment - Present on admission indicators - Hospital-acquired conditions - Coding guidelines for principal diagnosis selection - AHA Coding Clinic - Principal diagnosis assignment - Official Guidelines for Coding and Reporting updates - Discharge dispositions and transfers |
| Professionalism, ethics, and compliance | 9.17% | - Potential DRG creep - Compliance risks indicated by PEPPER - Leading queries - DRG compliance initiatives - Medical record confidentiality - CDI department goals beyond reimbursement |
| Medical record documentation | 19.17% | - Physician query formats - Addressing diagnoses without clinical support - Situations in which queries are not appropriate - Compliant and noncompliant queries - Health record elements used for diagnosis and procedure code assignment - When a physician query is warranted - ACDIS/AHIMA Guidelines for Achieving a Compliant Query Practice - Provider role and diagnosis code assignment - Translating clinical indicators into compliant queries - Types of physician queries - Clinical indicators - Documentation requiring clarification |
| Healthcare regulations, reimbursement, and documentation requirements related to the IPPS | 12.5% | - IPPS and its updates and revisions - Medical staff and clinical staff documentation responsibilities - Inpatient admission criteria and CMS Two-Midnight Rule - Documentation impact on IPPS reimbursement - Case mix index (CMI) - Medicare contractors and their impact on CDI - Medicare Severity Diagnosis Related Groups (MS-DRGs) - Principal diagnosis and medical necessity - Documentation and medical necessity of setting - Coding and billing practices vulnerable to denial - Complication/comorbidity (CC) - Major complication/comorbidity (MCC) |
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NEW QUESTION # 144
The amount of the IPPS Indirect Medical Education Adjustment is determined by teaching intensity as measured by the hospital's number of residents compared to:
Answer: D
Explanation:
Medicare's Indirect Medical Education (IME) adjustment uses the hospital's resident-to-bed ratio as the principal measure of teaching intensity. CMS explains that the IME adjustment factor is calculated using a hospital's ratio of residents to beds. Therefore, the correct answer is inpatient beds.
IME is an additional IPPS payment intended to recognize the higher indirect patient-care costs associated with operating an approved teaching program. These costs are distinguished from Direct Graduate Medical Education payments, which reimburse qualifying direct costs associated with residency training.
The number of admissions is not the denominator in the IME teaching-intensity calculation. Likewise, emergency-department beds are not simply combined with inpatient beds for the standard resident-to-bed ratio, and disproportionate-share payment rates represent a separate IPPS adjustment related principally to hospitals caring for substantial numbers of low-income patients.
For the CCDS examination, the important distinction is that IPPS reimbursement involves more than the base MS-DRG payment. Adjustments may include IME, disproportionate-share hospital provisions, wage-index effects, outlier payments, and other statutory mechanisms.
CCDS Reference Topics: IPPS reimbursement; teaching hospitals; IME adjustment; resident-to-bed ratio.
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NEW QUESTION # 145
A wound care nurse documents an assessment and care of a pressure ulcer. For coding purposes, the wound care nurse's documentation can be used to assign which of the following?
Answer: A
Explanation:
The wound care nurse's documentation may be used to establish the stage of a pressure ulcer, making option D correct. ICD-10-CM provides specific exceptions to the general rule that diagnosis code assignment is based on documentation by a provider legally accountable for establishing diagnoses. Pressure-ulcer staging is one of the clinical details that may be derived from documentation by qualified non-provider clinicians involved in the patient's care.
Wound care nurses possess specialized expertise in pressure-injury assessment and commonly document staging based on tissue involvement. Current ICD-10-CM guidance directs assignment of the pressure-ulcer stage according to clinical documentation and provides specific rules for unstageable ulcers, healing ulcers, and ulcers that progress during hospitalization.
This exception does not mean that a wound-care nurse independently establishes every element of the medical diagnosis for coding purposes. The provider documentation remains central to identifying the pressure-ulcer diagnosis and relevant clinical condition, while the stage may come from qualified clinician documentation.
POA assignment follows separate reporting rules and is based on whether the condition was present at the time inpatient admission occurred.
CCDS Reference Topics: Pressure ulcers; non-provider documentation; staging; coding conventions.
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NEW QUESTION # 146
What type of query is needed to compliantly address a scenario in which clinical indicators of a diagnosis exist, but for which no diagnosis has been documented in the medical record?
Answer: B
Explanation:
A multiple-choice query is appropriate when clinical indicators support the possibility of a condition but the diagnosis itself has not yet been documented. The query may present clinically reasonable diagnostic choices supported by the patient's record while also allowing an alternative response such as "other, please specify" or an inability to determine.
A yes/no query is not the appropriate format for introducing a new, previously undocumented diagnosis.
AHIMA/ACDIS guidance has specifically distinguished this situation from circumstances where yes/no clarification may be used for an already documented condition, POA determination, cause-and-effect clarification, or similar defined purposes.
A clinical-validation query addresses the opposite problem: a diagnosis is already documented, but the health record appears to lack sufficient clinical support for that diagnosis. Therefore, option C does not match the scenario.
A cause-and-effect query would be appropriate when two documented conditions require clarification of their relationship, not when the fundamental issue is the absence of a diagnosis.
Current AHIMA/ACDIS guidance continues to permit multiple-choice queries supported by relevant clinical indicators and emphasizes neutral wording.
CCDS Reference Topics: Compliant query formats; missing diagnosis; clinical validation; nonleading queries.
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NEW QUESTION # 147
A CDI specialist reviews the MS-DRG mismatch report and notes a difference in a case. The coder noted that a current Coding Clinic affects the final coding of the record, which changed the MS-DRG assignment. To BEST understand this discrepancy, the specialist should FIRST:
Answer: B
Explanation:
The CDI specialist should first review the final coded record together with the Coding Clinic guidance identified by the coder. This provides an objective basis for understanding why the final MS-DRG differs from the CDI working DRG.
A mismatch does not automatically indicate that either CDI or coding made an error. Working DRGs are provisional and may change after complete review of discharge documentation, operative reports, pathology, final diagnostic information, coding conventions, official guidelines, or authoritative Coding Clinic advice.
Reviewing the applicable guidance before contacting the coder promotes an informed and efficient reconciliation process. Once the specialist understands the coding rule, discussion with the coder may still be useful if ambiguity remains. Immediately escalating to the coding manager is unnecessary unless the issue cannot be resolved through normal collaboration. Forwarding the record without investigating the mismatch would defeat the purpose of a reconciliation process and could allow recurring education opportunities to remain unidentified.
Mismatch analysis is a valuable CDI quality metric because it can identify documentation gaps, coding- knowledge issues, changes in authoritative guidance, and opportunities to improve CDI/coding alignment.
CCDS Reference Topics: MS-DRG reconciliation; CDI/coder collaboration; Coding Clinic application; CDI program analysis.
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NEW QUESTION # 148
A hospital has a total MS-DRG relative weight of 2,640 for 1,600 inpatient discharges. What is its case mix index?
Answer: A
Explanation:
Case mix index is calculated by dividing the sum of MS-DRG relative weights by the number of inpatient discharges:
2,640 ÷ 1,600 = 1.65
Therefore, the CMI is 1.65.
CMI represents the average relative resource intensity of the hospital's inpatient cases. It is affected by the types of patients treated, surgical versus medical mix, tertiary services, transplant or trauma volume, documentation specificity, coding accuracy, and annual changes to MS-DRG relative weights and grouper logic.
CMS publishes hospital case-mix information and FY 2026 relative weighting factors through the IPPS Final Rule supporting data. Table 5 contains MS-DRGs and relative weighting factors, while Table 2 contains hospital-specific case-mix information.
A decline in CMI should not automatically be interpreted as a CDI failure. A shift toward lower-complexity cases or changes in service lines can legitimately reduce CMI even with excellent documentation.
CDI managers should therefore trend CMI alongside diagnosis capture, surgical volume, service lines, payer population, coding reconciliation, and quality indicators.
CCDS Reference Topics: Case mix index; MS-DRG relative weight; CDI analytics; hospital performance.
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NEW QUESTION # 149
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