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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 |
| Healthcare regulations, reimbursement, and documentation requirements related to the IPPS | 12.5% | - IPPS, MS-DRGs, reimbursement, and medical necessity - CC/MCC, CMI, Medicare contractors, and compliance |
| Professionalism, ethics, and compliance | 9.17% | - Query compliance, DRG creep, and audit risks - Confidentiality, DRG compliance, and ethical CDI practices |
| Impact of reportable diagnoses on quality of care | 8.33% | - Quality metrics, reporting programs, and financial impact - Mortality, severity of illness, and risk of mortality |
| Anatomy and physiology, pathophysiology, pharmacology, and medical terminology | 19.17% | - Clinical conditions and clinical indicators - Anatomy, physiology, pathophysiology, pharmacology, and terminology |
| Medical record documentation | 19.17% | - Documentation clarification and compliant physician queries - Documentation requirements and diagnosis or procedure code assignment |
| Official Guidelines for Coding and Reporting | 14.17% | - Coding guidelines, AHA Coding Clinic, HACs, and POA indicators - Principal and secondary diagnosis assignment |
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NEW QUESTION # 95
Which of the following diagnoses is classified as a major complication/comorbidity (MCC) under the FY
2026 MS-DRG system?
Answer: C
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 # 96
Which pressure-ulcer category is specifically included in the traditional CMS HAC payment policy when the condition is not present on admission?
Answer: C
Explanation:
CMS's Hospital-Acquired Condition payment framework specifically identifies Stage III and Stage IV pressure ulcers among the defined HAC categories when applicable conditions are not present on admission.
The distinction is important because not every pressure injury automatically triggers HAC payment treatment.
Stage and POA status therefore require accurate documentation.
A hospital-acquired pressure ulcer remains reportable even when HAC payment provisions apply. CMS does not instruct hospitals to suppress or omit such conditions. Instead, defined HAC diagnoses that are not POA may lose the CC/MCC payment effect they otherwise would contribute to the MS-DRG, subject to applicable grouper rules.
The CDI specialist should ensure that wound location, laterality when relevant, stage, progression, and timing are accurately documented. Qualified wound-care nurse documentation may be used for pressure-ulcer staging under the ICD-10-CM non-provider documentation exception, while the diagnosis itself remains subject to provider-documentation requirements.
CDI professionals must also distinguish the HAC/POA MS-DRG payment provision from the separate HAC Reduction Program, which reduces applicable hospital payments by 1% for hospitals in the worst-performing quartile.
CCDS Reference Topics: HACs; pressure ulcers; POA; MS-DRG adjustment; wound documentation.
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NEW QUESTION # 97
A CDI specialist reviews a prior hospitalization and finds that the patient previously had chronic systolic heart failure. During the current admission, the provider documents only "history of CHF," although the patient remains on long-term heart-failure therapy. What is the BEST approach?
Answer: C
Explanation:
Prior-encounter information may provide valuable clinical context, but it should not automatically be imported as a current reportable diagnosis without considering whether the condition remains active and relevant to the present encounter.
Here, a prior diagnosis of chronic systolic heart failure, ongoing heart-failure therapy, and ambiguous current wording such as "history of CHF" create a reasonable opportunity to clarify the patient's current heart-failure status if that information is clinically relevant.
The CDI specialist should not independently carry forward the previous diagnosis or escalate it to acute heart failure. Conversely, rigidly ignoring reliable prior clinical information can prevent identification of legitimate documentation gaps.
The 2026 ACDIS/AHIMA query guidance specifically includes the role of prior encounters as part of its updated query-practice framework, while emphasizing compliant provider clarification and accurate representation of the current patient's clinical status.
A query should make clear which current clinical indicators support the need for clarification and should not imply that a previous diagnosis must automatically remain valid.
CCDS Reference Topics: Prior encounters; chronic conditions; heart failure; query practice; current- encounter documentation.
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NEW QUESTION # 98
A CDI program is developing a query escalation policy. A clinically significant query remains unanswered despite normal reminders. Which action is MOST appropriate?
Answer: D
Explanation:
An unanswered clinically significant query should be managed through the organization's defined escalation process. The process may involve CDI leadership, coding leadership, a physician advisor, department leadership, or other designated personnel, depending on organizational policy.
Neither CDI nor coding may independently supply the missing diagnosis because diagnostic conclusions remain the provider's responsibility. Removing an unresolved query simply to accelerate billing can undermine documentation integrity and may create compliance problems.
Escalation policies should be standardized rather than applied only when a particular diagnosis affects reimbursement. Policies commonly address expected response time, reminder intervals, responsible escalation personnel, high-priority queries, retrospective queries, and final-bill procedures.
The 2026 ACDIS/AHIMA Guidelines for Achieving a Compliant Query Practice supersede prior versions and serve as the current foundational guidance for organizations establishing compliant query policies and procedures.
A mature escalation process balances timely claim completion with respect for provider workload and independent clinical judgment. Its purpose is obtaining complete and accurate documentation, not forcing agreement with a CDI-generated diagnosis.
CCDS Reference Topics: Query escalation; organizational policy; unanswered queries; compliance; provider responsibility.
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NEW QUESTION # 99
A patient's baseline creatinine is 1.1 mg/dL. On admission it is 1.2 mg/dL, and 36 hours later it rises to 2.4 mg
/dL after prolonged hypotension. Urine output declines substantially. Which condition presents the strongest clarification opportunity?
Answer: A
Explanation:
The abrupt increase in serum creatinine and reduction in urine output strongly support consideration of acute kidney injury (AKI). The patient's creatinine approximately doubled from the established baseline within a short period, and the episode follows significant hypotension, a recognized cause of acute renal hypoperfusion and potentially ischemic tubular injury.
Chronic kidney disease cannot be established from an acute creatinine change alone. CKD requires evidence that renal abnormalities persist chronically, generally over a period of at least several months. End-stage renal disease represents advanced chronic renal failure and is clearly unsupported by this scenario. Nephrotic syndrome would require a different constellation, particularly substantial proteinuria, hypoalbuminemia, and edema.
The CDI specialist should not independently diagnose AKI based solely on laboratory values. Rather, these findings provide the clinical basis for a neutral provider query if the diagnosis has not been documented.
Relevant indicators could include baseline and current creatinine, urine output, hypotension, fluid resuscitation, nephrology assessment, medications, and renal replacement therapy if applicable.
The CCDS competency framework expects candidates to interpret renal laboratory findings and recognize clinically significant documentation opportunities.
CCDS Reference Topics: Acute kidney injury; renal pathophysiology; creatinine trends; clinical indicators.
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NEW QUESTION # 100
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