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| Section | Weight | Objectives |
|---|---|---|
| Topic 1: Clinical Documentation Review & Query Practices | 20% | - Documentation gap identification and resolution - Concurrent and retrospective chart review methodologies - Query development, communication, and ethical standards |
| Topic 2: Coding Guidelines & Official Reporting Standards | 15% | - AHIMA/ACDIS Guidelines for Compliant Query Practice - ICD-10-CM/PCS Official Guidelines for Coding and Reporting - Coding integrity and compliant documentation practices |
| Topic 3: Quality, Risk Adjustment & Health Initiatives | 15% | - Risk adjustment models and documentation impact - Severity of Illness (SOI) / Risk of Mortality (ROM) - Quality reporting, public reporting, and compliance programs |
| Topic 4: CDI Program Management & Professional Practice | 15% | - Program metrics, benchmarks, and performance measurement - Ethics, HIPAA, and professional conduct - Provider education and training strategies |
| Topic 5: Healthcare Regulations, Reimbursement & Documentation Requirements – IPPS | 15% | - Inpatient Prospective Payment System (IPPS) fundamentals - Documentation responsibilities of medical and clinical staff - Medicare Severity Diagnostic Related Groups (MS-DRGs) |
| Topic 6: Clinical Knowledge & Disease Processes Application | 20% | - Clinical indicators, lab results, medications, diagnostic findings - Disease processes across body systems applied to chart review - Medical terminology, anatomy, physiology, pathophysiology |
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問題 #19
The attending physician documents "severe protein-calorie malnutrition." The dietitian's assessment documents normal nutritional intake, stable body weight, no fat loss, and no muscle wasting. What should the CDI specialist do?
答案：D
解題說明：
This is an appropriate clinical validation query because the provider has documented a diagnosis while the available clinical information appears inconsistent with that diagnosis.
The CDI specialist should not automatically accept every documented diagnosis when substantial contradictory clinical evidence exists. Conversely, CDI cannot independently delete the physician's diagnosis or replace the physician's clinical judgment.
The query should objectively identify the documented severe malnutrition and relevant contradictory findings-for example, stable weight, adequate nutritional intake, and absence of documented muscle or fat loss-and ask the provider to clarify whether severe malnutrition remains clinically appropriate, whether another nutritional condition better describes the patient, whether the diagnosis has been ruled out, or whether additional clinical reasoning supports it.
The query must remain neutral and should not mention the MCC status or potential reimbursement effect of severe malnutrition.
The August 2026 ACDIS/AHIMA compliant-query guidance supersedes previous editions and is the current foundational standard for compliant documentation clarification.
CCDS Reference Topics: Clinical validation; malnutrition; conflicting clinical indicators; compliant queries; documentation integrity.
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問題 #20
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?
答案：B
解題說明：
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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問題 #21
A registered dietitian documents severe malnutrition based on substantial weight loss, severe muscle depletion, and prolonged inadequate energy intake. The attending physician documents only "poor oral intake." What is the BEST action for the CDI specialist?
答案：D
解題說明：
The appropriate action is to query the provider regarding the patient's nutritional diagnosis. The dietitian's assessment supplies important clinical evidence, but the associated diagnosis of malnutrition generally must be documented by an appropriate provider before the diagnosis code is assigned.
The FY 2026 ICD-10-CM Official Guidelines permit selected elements to come from non-provider clinicians-such as BMI, pressure-ulcer stage, coma scale, NIH Stroke Scale, certain social determinants, and other specifically identified exceptions. Malnutrition diagnosis itself is not simply assigned solely from a dietitian's diagnostic statement under this general rule.
Ignoring the dietitian's findings would also be inappropriate. CDI review should integrate multidisciplinary documentation because such documentation can reveal valid clarification opportunities. Severe weight loss, reduced intake, and documented muscle depletion provide a clinical basis for a neutral query.
The query should not state that severe malnutrition "must" be documented because it is an MCC. Instead, it should present the relevant nutrition findings and allow the provider to determine the diagnosis, including severe malnutrition, another level of malnutrition, another cause, or inability to determine.
CCDS Reference Topics: Malnutrition; multidisciplinary documentation; provider diagnosis requirements; clinical indicators.
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問題 #22
The table below shows physician performance:
Which of the following physicians will have the most favorable mortality rate on a public website, such as Healthgrades.com?
答案：C
解題說明：
Physician 4 has the most favorable risk-adjusted mortality rate, at 1.3, compared with Physician 1 at 1.5, Physician 2 at 2.0, and Physician 3 at 2.5. Although Physician 1 has fewer observed deaths and an observed mortality rate of 1.6%, public outcome comparisons commonly incorporate risk adjustment rather than relying solely on raw mortality. Risk adjustment attempts to account for differences in patient complexity, comorbid disease burden, demographic factors, and other characteristics that influence expected outcomes.
This is directly relevant to CDI because incomplete documentation of clinically significant comorbidities can understate patient severity and therefore adversely affect the expected mortality component of risk-adjusted performance calculations. Conversely, accurate documentation allows coded data to represent the actual severity and risk of the population being treated. Healthgrades specifically states that its mortality methodology adjusts for patient risk factors to permit more meaningful comparisons of clinical outcomes.
The CCDS content outline specifically requires knowledge of mortality indices, severity of illness/risk of mortality, physician performance, and the effect of documentation on publicly reported data.
CCDS Reference Topics: Impact of reportable diagnoses on quality of care; Healthcare facility CDI program analysis; mortality index and risk adjustment.
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問題 #23
Based on the AHIMA/ACDIS Practice Brief Guidelines for Achieving a Compliant Query Practice, a leading query is one that:
答案：A
解題說明：
A query becomes problematic when it directs or influences the provider toward a diagnosis that is not supported by the patient's clinical record. Therefore, option C most accurately represents the leading-query concept in this answer set. A compliant query must be based on patient-specific clinical indicators and must preserve the provider's independent clinical judgment.
A multiple-choice query may include a diagnosis not previously documented when that diagnosis is supported by the clinical indicators and when reasonable alternatives are also offered. ACDIS/AHIMA guidance has specifically recognized that presenting a clinically supported new diagnosis among neutral choices does not automatically make the query leading.
Likewise, the timing of a query while a provider is documenting does not make it leading. Cause-and-effect clarification may also be addressed using an appropriate query format when both conditions are documented and the relationship remains uncertain.
The current 2026 ACDIS/AHIMA Guidelines for Achieving a Compliant Query Practice supersede the prior versions and continue to establish compliant provider-query practice as a foundational CDI standard. Queries must be clinically supported, noncoercive, and constructed without reference to reimbursement or other desired outcomes.
CCDS Reference Topics: Leading queries; clinical indicators; compliant query construction; provider independence.
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問題 #24
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