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| Section | Weight | Objectives |
|---|---|---|
| Topic 1: Impact of reportable diagnoses on quality of care | 8.33% | - Hospital Value-Based Purchasing - CDI impact on Hospital Value-Based Purchasing - Hospital-Acquired Condition Reduction Program - 30-day mortality measures - Quality data from record abstraction and claims data - Documentation and code assignment impact on mortality index - Patient Safety Indicators - Mortality reviews and observed/expected ratios - Hospital Inpatient Quality Reporting Program - Healthcare-associated infections and complication codes - Hospital Readmissions Reduction Program - Coded data elements affecting Patient Safety Indicators |
| Topic 2: Anatomy and physiology, pathophysiology, pharmacology, and medical terminology | 19.17% | - Diseases and disorders of the digestive system - Infectious and parasitic diseases - Injuries, poisonings, and toxic effects of drugs - Diagnostic tests as clinical indicators - Endocrine, nutritional, and metabolic diseases and disorders - Diseases and disorders of the circulatory system - Diseases and disorders of the kidney and urinary tract - Standard medical abbreviations - Diseases and disorders of the respiratory system - Diseases and disorders of the skin, subcutaneous tissue, and breast - Diseases and disorders of the musculoskeletal system - Pharmaceuticals and disease processes - Myeloproliferative diseases and disorders and poorly differentiated neoplasms - Clinical indicators and query opportunities by Major Diagnostic Category - HIV infections - Diseases and disorders of the blood and blood-forming organs and immunological disorders - Medications as clinical indicators - Diseases and disorders of the nervous system - Diseases and disorders of the hepatobiliary system - Mental diseases and disorders - Alcohol/drug use and alcohol/drug-induced organic brain disorders |
| Topic 3: Official Guidelines for Coding and Reporting | 14.17% | - Discharge dispositions and transfers - Coding guidelines for principal diagnosis selection - Hospital-acquired conditions - Secondary diagnosis assignment - Present on admission indicators - AHA Coding Clinic - Official Guidelines for Coding and Reporting updates - Principal diagnosis assignment - Working DRG assignment for multiple diagnoses |
| Topic 4: Healthcare facility CDI program analysis | 8.33% | - PEPPER data - CDI program forecasting - Severity of illness and risk of mortality - CC/MCC capture - Publicly reported data - Physician performance measurement - Hospital Value-Based Purchasing measures - CDI specialist productivity metrics - Patient Safety Indicators - Hospital-specific financial data - Tracking and trending physician, department, and hospital performance - Case mix index (CMI) - High-frequency DRGs - Provider response rates - Basic computer and software application skills |
| Topic 5: Medical record documentation | 19.17% | - Translating clinical indicators into compliant queries - Health record elements used for diagnosis and procedure code assignment - Compliant and noncompliant queries - Provider role and diagnosis code assignment - Types of physician queries - Situations in which queries are not appropriate - Documentation requiring clarification - Clinical indicators - Physician query formats - ACDIS/AHIMA Guidelines for Achieving a Compliant Query Practice - When a physician query is warranted - Addressing diagnoses without clinical support |
| Topic 6: Communication skills | 9.17% | - Roles and responsibilities of coders working with CDI departments - Effective and non-confrontational physician communication - Reconciling CDI working DRGs with final coded DRGs - Physician education forms and tools - Verbal versus written physician communication - Educational presentations for healthcare departments and administration - Roles and responsibilities of CDI specialists |
| Topic 7: Healthcare regulations, reimbursement, and documentation requirements related to the IPPS | 12.5% | - Complication/comorbidity (CC) - Medicare contractors and their impact on CDI - Documentation and medical necessity of setting - Medical staff and clinical staff documentation responsibilities - Documentation impact on IPPS reimbursement - Medicare Severity Diagnosis Related Groups (MS-DRGs) - Major complication/comorbidity (MCC) - Case mix index (CMI) - Inpatient admission criteria and CMS Two-Midnight Rule - Coding and billing practices vulnerable to denial - Principal diagnosis and medical necessity - IPPS and its updates and revisions |
| Topic 8: Professionalism, ethics, and compliance | 9.17% | - CDI department goals beyond reimbursement - Potential DRG creep - DRG compliance initiatives - Compliance risks indicated by PEPPER - Leading queries - Medical record confidentiality |
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NEW QUESTION # 123
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: D
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 # 124
An operative report states that the surgeon performed an excisional debridement of a heel wound. The report documents removal of necrotic tissue but does not identify the deepest tissue level removed. What should the CDI specialist clarify?
Answer: B
Explanation:
For excisional debridement, documentation of the deepest tissue level actually removed is essential for accurate ICD-10-PCS procedure assignment. Relevant levels may include skin, subcutaneous tissue, fascia, muscle, or bone.
The presence of a deep wound does not establish that debridement reached the deepest anatomical layer visible in the wound. For example, a wound may extend to muscle while the physician removes only necrotic subcutaneous tissue. Coding must reflect the body part and tissue actually debrided rather than the overall depth of the wound.
Therefore, the CDI specialist should clarify what tissue was excised. Other procedural elements may already be supported by the operative documentation, including the excisional nature of the procedure.
The number of instruments or duration of anesthesia does not determine the applicable body-part value.
Similarly, administrative details have no bearing on procedural specificity.
CDI specialists working with surgical records must understand the distinction between wound description and procedure performance. Accurate procedural documentation can affect ICD-10-PCS coding and ultimately MS-DRG assignment, particularly when an operating-room procedure influences grouper logic.
The CCDS competency framework includes medical-record review and coding/payment implications of inpatient procedures.
CCDS Reference Topics: Excisional debridement; ICD-10-PCS; tissue depth; operative documentation.
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NEW QUESTION # 125
A CDI specialist sends a compliant query. The physician answers "other-viral syndrome" and supports the diagnosis in the progress note. The queried diagnosis would have been an MCC. What should the CDI specialist do?
Answer: B
Explanation:
The CDI specialist should accept the physician's clinically supported response. Querying is intended to clarify documentation, not to obtain a predetermined diagnosis or reimbursement result.
A compliant query should preserve the provider's independent clinical judgment. The physician may select one of the offered choices, document another diagnosis, rule out the suspected condition, or state that the diagnosis cannot be determined.
The fact that a different answer would qualify as an MCC is irrelevant to whether the provider's response should be respected.
Repeatedly issuing the same query because the initial response does not increase reimbursement risks creating a coercive or leading process and undermines documentation integrity.
A follow-up query could be justified if materially new clinical information appears or if the response itself remains internally contradictory or incomplete. But disagreement with the financial consequence is not sufficient.
The August 2026 ACDIS/AHIMA guidelines supersede all previous versions and are the current foundational resource for compliant query processes across healthcare settings.
CCDS Reference Topics: Provider autonomy; query response; MCC neutrality; ethical CDI practice; compliant querying.
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NEW QUESTION # 126
A CDI specialist drafts the following query:
"Please document acute respiratory failure because the patient's oxygen saturation is 84% and this diagnosis will qualify as an MCC." What is the MOST appropriate action?
Answer: D
Explanation:
The query should be rewritten as a neutral, clinically supported clarification request. The original wording is noncompliant because it directs the physician toward a particular diagnosis and explicitly identifies its reimbursement consequence.
The current ACDIS/AHIMA 2026 Guidelines for Achieving a Compliant Query Practice, released in August
2026, supersede prior versions and emphasize that the query process exists to ensure the health record accurately reflects the patient's clinical status.
A compliant query could present relevant findings such as oxygen saturation, respiratory rate, blood-gas values, oxygen requirements, work of breathing, escalation to noninvasive or invasive ventilation, and treatment. It should then request clarification using clinically reasonable choices or another compliant format without highlighting which answer produces an MCC.
An oxygen saturation of 84% may be an important indicator, but a CDI specialist may not convert that finding independently into respiratory failure. The provider must evaluate the complete clinical picture.
Approval from a coding manager does not cure biased wording. Substituting "CC" for "MCC" likewise leaves the fundamental compliance problem intact.
CCDS Reference Topics: Query compliance; leading queries; respiratory failure; ethical CDI practice.
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NEW QUESTION # 127
A CDI manager finds that cardiology providers receive repeated queries for heart-failure acuity and type.
Which educational intervention is MOST appropriate?
Answer: C
Explanation:
The most effective intervention is targeted, service-line-specific physician education based on actual documentation trends and clinically relevant examples.
Repeated queries for the same issue usually indicate a systematic documentation opportunity rather than isolated provider mistakes. Education should therefore show cardiologists how documentation of heart-failure type-such as systolic, diastolic, or combined-and acuity-acute, chronic, or acute on chronic- communicates the patient's clinical condition more precisely.
Using deidentified examples from the service line makes the education immediately relevant and enables physicians to recognize which clinical circumstances frequently generate clarification. Aggregate query data can demonstrate where documentation gaps occur without criticizing individual providers.
Sending an entire code book places coding responsibility on physicians and is unlikely to change documentation behavior. Stopping queries leaves unresolved clinical ambiguity. Framing the education around reduced reimbursement is also inappropriate because the goal of CDI education is accurate clinical representation, not coaching physicians toward higher-paying diagnoses.
The 2026 ACDIS/AHIMA query guidance identifies accurate representation of the patient's clinical status as the underlying purpose of CDI clarification.
CCDS Reference Topics: Physician education; communication; heart-failure specificity; query trend analysis.
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NEW QUESTION # 128
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