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| Section | Weight | Objectives |
|---|---|---|
| Topic 1: Official Guidelines for Coding and Reporting | 14.17% | - Discharge dispositions and transfers - Working DRG assignment for multiple diagnoses - Official Guidelines for Coding and Reporting updates - Secondary diagnosis assignment - Coding guidelines for principal diagnosis selection - Hospital-acquired conditions - Principal diagnosis assignment - Present on admission indicators - AHA Coding Clinic |
| Topic 2: Healthcare regulations, reimbursement, and documentation requirements related to the IPPS | 12.5% | - Inpatient admission criteria and CMS Two-Midnight Rule - Documentation impact on IPPS reimbursement - Medical staff and clinical staff documentation responsibilities - Medicare Severity Diagnosis Related Groups (MS-DRGs) - Principal diagnosis and medical necessity - Documentation and medical necessity of setting - IPPS and its updates and revisions - Coding and billing practices vulnerable to denial - Complication/comorbidity (CC) - Case mix index (CMI) - Major complication/comorbidity (MCC) - Medicare contractors and their impact on CDI |
| Topic 3: Medical record documentation | 19.17% | - Translating clinical indicators into compliant queries - Health record elements used for diagnosis and procedure code assignment - Types of physician queries - Physician query formats - Documentation requiring clarification - Provider role and diagnosis code assignment - Clinical indicators - When a physician query is warranted - ACDIS/AHIMA Guidelines for Achieving a Compliant Query Practice - Compliant and noncompliant queries - Situations in which queries are not appropriate - Addressing diagnoses without clinical support |
| Topic 4: Professionalism, ethics, and compliance | 9.17% | - Potential DRG creep - DRG compliance initiatives - CDI department goals beyond reimbursement - Leading queries - Compliance risks indicated by PEPPER - Medical record confidentiality |
| Topic 5: Healthcare facility CDI program analysis | 8.33% | - Patient Safety Indicators - Physician performance measurement - Provider response rates - CDI specialist productivity metrics - Hospital-specific financial data - CC/MCC capture - Tracking and trending physician, department, and hospital performance - Basic computer and software application skills - Publicly reported data - Case mix index (CMI) - Hospital Value-Based Purchasing measures - Severity of illness and risk of mortality - High-frequency DRGs - PEPPER data - CDI program forecasting |
| Topic 6: Anatomy and physiology, pathophysiology, pharmacology, and medical terminology | 19.17% | - Diseases and disorders of the hepatobiliary system - Diseases and disorders of the kidney and urinary tract - Mental diseases and disorders - Medications as clinical indicators - Diseases and disorders of the blood and blood-forming organs and immunological disorders - Pharmaceuticals and disease processes - Diseases and disorders of the digestive system - Diseases and disorders of the musculoskeletal system - HIV infections - Myeloproliferative diseases and disorders and poorly differentiated neoplasms - Alcohol/drug use and alcohol/drug-induced organic brain disorders - Diseases and disorders of the skin, subcutaneous tissue, and breast - Diseases and disorders of the circulatory system - Injuries, poisonings, and toxic effects of drugs - Diseases and disorders of the respiratory system - Standard medical abbreviations - Clinical indicators and query opportunities by Major Diagnostic Category - Diseases and disorders of the nervous system - Diagnostic tests as clinical indicators - Endocrine, nutritional, and metabolic diseases and disorders - Infectious and parasitic diseases |
| Topic 7: Impact of reportable diagnoses on quality of care | 8.33% | - Hospital-Acquired Condition Reduction Program - Coded data elements affecting Patient Safety Indicators - Hospital Readmissions Reduction Program - Patient Safety Indicators - Quality data from record abstraction and claims data - Mortality reviews and observed/expected ratios - Hospital Inpatient Quality Reporting Program - Documentation and code assignment impact on mortality index - CDI impact on Hospital Value-Based Purchasing - Hospital Value-Based Purchasing - Healthcare-associated infections and complication codes - 30-day mortality measures |
| Topic 8: Communication skills | 9.17% | - Physician education forms and tools - Verbal versus written physician communication - Effective and non-confrontational physician communication - Educational presentations for healthcare departments and administration - Roles and responsibilities of coders working with CDI departments - Reconciling CDI working DRGs with final coded DRGs - Roles and responsibilities of CDI specialists |
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102. Frage
The attending physician documents "acute systolic heart failure," while a consultant documents "chronic diastolic heart failure" for the same episode of care. Which provider should ultimately clarify the conflicting diagnostic documentation for coding purposes?
Antwort: B
Begründung:
The attending physician is the correct answer and this scenario is adapted from an official ACDIS CCDS sample item addressing conflicting medical-record documentation.
ICD-10-CM coding depends on provider documentation, but when clinically significant documentation conflicts within the record, the discrepancy must be clarified rather than resolved independently by the coder or CDI specialist. The FY 2026 Official Guidelines specifically state that when medical-record documentation conflicts, the patient's provider should be queried for clarification.
In the inpatient environment, the attending provider is generally responsible for synthesizing the patient's diagnoses and final clinical picture. A consultant's documentation may supply essential clinical information and may support code assignment when there is no conflict, but conflicting descriptions of heart-failure type or acuity should not simply be selected based on which diagnosis produces the higher-severity code.
The query should identify the conflicting statements objectively and request clarification of the clinically appropriate diagnosis. It should not suggest which diagnosis should be selected or mention reimbursement consequences.
This concept is central to CDI because unresolved contradictions can affect MS-DRG assignment, risk adjustment, severity measurement, quality reporting, and the clinical integrity of the record.
CCDS Reference Topics: Conflicting documentation; provider clarification; heart-failure specificity; medical-record integrity.
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103. Frage
A patient without chronic hypercapnia develops severe respiratory distress. ABG results are pH 7.19, PaCO#
74 mmHg, and PaO# 60 mmHg. The patient requires emergent BiPAP. Which condition is MOST strongly supported for clarification?
Antwort: C
Begründung:
The findings strongly support clarification of acute hypercapnic respiratory failure. PaCO# of 74 mmHg represents marked carbon dioxide retention, while pH 7.19 demonstrates significant respiratory acidemia. The patient is also hypoxemic and requires urgent noninvasive ventilatory assistance.
Because there is no documented chronic hypercapnic baseline, the available information primarily supports an acute process rather than chronic respiratory failure.
Acute hypercapnia occurs when alveolar ventilation becomes insufficient to eliminate carbon dioxide.
Potential causes include COPD or asthma exacerbation, central nervous system depression, neuromuscular weakness, obesity hypoventilation, airway obstruction, or severe fatigue.
BiPAP provides positive-pressure ventilatory support and can improve alveolar ventilation, decrease work of breathing, and lower PaCO#.
The CDI specialist should not independently establish respiratory failure solely from an ABG. However, the combination of severe physiologic abnormality, respiratory distress, and escalation to BiPAP supplies a strong basis for provider clarification when no corresponding diagnosis is documented.
Metabolic alkalosis would ordinarily involve primary bicarbonate elevation with alkalemia rather than profound respiratory acidemia.
CCDS Reference Topics: Acute respiratory failure; hypercapnia; ABG interpretation; noninvasive ventilation; clinical indicators.
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104. Frage
A patient was admitted with weakness, loss of appetite, hemoglobin 7.8, WBC 2,700, and platelet count 58.
The admitting diagnoses on the history and physical were anemia, leukopenia, decreased platelets, and rule out myelodysplastic syndrome. Based on these clinical indicators a CDI specialist should query for which of the following conditions?
Antwort: C
Begründung:
The laboratory findings demonstrate reduction in all three major peripheral blood-cell lines: hemoglobin 7.8 indicates anemia, WBC 2,700 indicates leukopenia, and platelets 58 indicate thrombocytopenia. Collectively, this pattern is consistent with pancytopenia, making option C the most appropriate documentation clarification.
The National Cancer Institute defines pancytopenia as a lower-than-normal number of red blood cells, white blood cells, and platelets. Importantly, pancytopenia describes the hematologic state; it does not establish its underlying etiology. Myelodysplastic syndrome was only being ruled out in the scenario, so the CDI specialist should not infer it as the definitive cause.
Thrombocytopenia alone would capture only one component of the abnormal CBC and would fail to represent the simultaneous anemia and leukopenia. Myelophthisis implies marrow displacement or infiltration and cannot be inferred from these counts alone. Likewise, aplastic anemia is a specific bone-marrow failure diagnosis requiring provider determination and supporting diagnostic evaluation.
A compliant query can present pancytopenia as a clinically supported choice while allowing the provider to document another explanation.
CCDS Reference Topics: Hematology; clinical indicators; medical terminology; compliant query opportunity.
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105. Frage
Which statement BEST describes the basic funding mechanism of the Hospital Value-Based Purchasing Program?
Antwort: C
Begründung:
The Hospital Value-Based Purchasing Program is designed as a budget-neutral program. CMS funds it by reducing participating hospitals' base operating DRG payments by 2% and redistributing the amount through value-based incentive payments based on program performance.
This mechanism is different from the HAC Reduction Program, which imposes a 1% reduction on applicable hospitals in the worst-performing quartile. The two programs should not be confused even though both connect hospital quality performance with Medicare reimbursement.
Hospital VBP performance encompasses multiple quality domains rather than simply determining whether individual HACs occurred. Documentation integrity is relevant because coded diagnoses and clinical information can contribute to risk adjustment and quality-measure calculations.
However, CDI professionals should not seek additional diagnoses merely to affect VBP performance. Their role is to ensure that documented and coded data accurately represent the patient's actual severity, comorbidities, treatments, and outcomes.
For FY 2026, CMS publishes actual Hospital VBP adjustment factors used for eligible discharges and includes those factors within its IPPS final-rule materials.
CCDS Reference Topics: Hospital VBP; IPPS; value-based reimbursement; quality measures; payment methodology.
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106. Frage
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?
Antwort: C
107. Frage
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