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| Section | Weight | Objectives |
|---|---|---|
| Topic 1: Healthcare regulations, reimbursement, and documentation requirements related to the IPPS | 12.5% | - Complication/comorbidity (CC) - Case mix index (CMI) - Medicare Severity Diagnosis Related Groups (MS-DRGs) - Documentation and medical necessity of setting - Medical staff and clinical staff documentation responsibilities - IPPS and its updates and revisions - Major complication/comorbidity (MCC) - Inpatient admission criteria and CMS Two-Midnight Rule - Coding and billing practices vulnerable to denial - Medicare contractors and their impact on CDI - Documentation impact on IPPS reimbursement - Principal diagnosis and medical necessity |
| Topic 2: Healthcare facility CDI program analysis | 8.33% | - Basic computer and software application skills - CDI specialist productivity metrics - Case mix index (CMI) - Tracking and trending physician, department, and hospital performance - Patient Safety Indicators - Severity of illness and risk of mortality - Publicly reported data - Provider response rates - PEPPER data - CDI program forecasting - CC/MCC capture - Hospital-specific financial data - High-frequency DRGs - Hospital Value-Based Purchasing measures - Physician performance measurement |
| Topic 3: Communication skills | 9.17% | - Educational presentations for healthcare departments and administration - Verbal versus written physician communication - Effective and non-confrontational physician communication - Reconciling CDI working DRGs with final coded DRGs - Physician education forms and tools - Roles and responsibilities of coders working with CDI departments - Roles and responsibilities of CDI specialists |
| Topic 4: Medical record documentation | 19.17% | - Translating clinical indicators into compliant queries - Physician query formats - ACDIS/AHIMA Guidelines for Achieving a Compliant Query Practice - Addressing diagnoses without clinical support - Provider role and diagnosis code assignment - Compliant and noncompliant queries - Situations in which queries are not appropriate - Health record elements used for diagnosis and procedure code assignment - Types of physician queries - When a physician query is warranted - Clinical indicators - Documentation requiring clarification |
| Topic 5: Impact of reportable diagnoses on quality of care | 8.33% | - Hospital Value-Based Purchasing - Hospital Readmissions Reduction Program - Coded data elements affecting Patient Safety Indicators - Hospital-Acquired Condition Reduction Program - Hospital Inpatient Quality Reporting Program - Patient Safety Indicators - Documentation and code assignment impact on mortality index - Quality data from record abstraction and claims data - Healthcare-associated infections and complication codes - CDI impact on Hospital Value-Based Purchasing - 30-day mortality measures - Mortality reviews and observed/expected ratios |
| Topic 6: Anatomy and physiology, pathophysiology, pharmacology, and medical terminology | 19.17% | - Diseases and disorders of the kidney and urinary tract - Clinical indicators and query opportunities by Major Diagnostic Category - Standard medical abbreviations - Diseases and disorders of the musculoskeletal system - Alcohol/drug use and alcohol/drug-induced organic brain disorders - Diseases and disorders of the hepatobiliary system - Diseases and disorders of the circulatory system - Myeloproliferative diseases and disorders and poorly differentiated neoplasms - Pharmaceuticals and disease processes - Diseases and disorders of the skin, subcutaneous tissue, and breast - Injuries, poisonings, and toxic effects of drugs - Infectious and parasitic diseases - Mental diseases and disorders - Diseases and disorders of the respiratory system - Diseases and disorders of the nervous system - HIV infections - Diagnostic tests as clinical indicators - Endocrine, nutritional, and metabolic diseases and disorders - Diseases and disorders of the digestive system - Diseases and disorders of the blood and blood-forming organs and immunological disorders - Medications as clinical indicators |
| Topic 7: Professionalism, ethics, and compliance | 9.17% | - Leading queries - DRG compliance initiatives - Medical record confidentiality - CDI department goals beyond reimbursement - Potential DRG creep - Compliance risks indicated by PEPPER |
| Topic 8: Official Guidelines for Coding and Reporting | 14.17% | - Discharge dispositions and transfers - Official Guidelines for Coding and Reporting updates - Coding guidelines for principal diagnosis selection - Secondary diagnosis assignment - Present on admission indicators - Hospital-acquired conditions - AHA Coding Clinic - Working DRG assignment for multiple diagnoses - Principal diagnosis assignment |
>> CCDS Valid Test Questions <<
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NEW QUESTION # 124
A patient with type 2 diabetes mellitus is admitted with stage 4 chronic kidney disease. The physician documents both conditions but does not explicitly state that the CKD is caused by diabetes. No documentation indicates that the conditions are unrelated. Which of the following is the MOST appropriate coding approach?
Answer: A
Explanation:
ICD-10-CM permits a presumed causal relationship between diabetes mellitus and certain conditions indexed under "diabetes, with," including chronic kidney disease. Therefore, when diabetes and CKD are both documented and the provider has not specifically indicated that they are unrelated, the diabetes-with-CKD combination code is assigned together with an additional code identifying the CKD stage.
For type 2 diabetes, diabetic CKD is classified to E11.22, while an N18.- code identifies the documented CKD stage. In this scenario, stage 4 CKD would be additionally represented by the appropriate stage-specific N18 code.
A query is not routinely necessary simply to obtain wording such as "diabetic CKD" when the classification itself establishes the presumed relationship. However, clarification would be appropriate if documentation explicitly states another unrelated etiology or contains contradictory information.
This distinction is important for CDI because excessive querying can create unnecessary provider burden.
CDI specialists must understand which diagnostic relationships require explicit provider linkage and which are established through ICD-10-CM conventions.
The FY 2026 Official Guidelines remain applicable to discharges through September 30, 2026.
CCDS Reference Topics: Diabetes; CKD; presumed causal relationships; combination codes; coding conventions.
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NEW QUESTION # 125
A physician responds to a clinically supported CDI query by stating that the proposed diagnosis does not apply and documents a different diagnosis supported by the patient's condition. What is the BEST action by the CDI specialist?
Answer: A
Explanation:
The CDI specialist should respect the provider's independent clinical judgment, provided the response clearly addresses the query and the resulting documentation is clinically coherent.
A query is a request for clarification-not a mechanism for compelling the provider to select CDI's preferred diagnosis. Physician disagreement is therefore not inherently a failed query. The provider may appropriately document another condition, rule out a suspected condition, or explain why the indicators have another clinical interpretation.
Repeatedly querying until a desired diagnosis appears creates serious compliance risk and can undermine the integrity of the documentation process. Escalation may be appropriate in defined circumstances-for example, unresolved contradictions, unanswered high-priority queries, or persistent clinical-validation issues-but should follow organizational policy and should not occur merely because CDI dislikes the provider's answer.
The 2026 ACDIS/AHIMA guidance is the current foundational query-practice standard and emphasizes compliant clarification across healthcare settings.
Effective CDI communication requires clinical knowledge, professional dialogue, and recognition that final diagnostic determinations belong to the responsible provider.
CCDS Reference Topics: Physician communication; query responses; provider independence; escalation; professional conduct.
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NEW QUESTION # 126
Under the Hospital Readmissions Reduction Program, what is the maximum payment reduction applicable to an eligible hospital?
Answer: C
Explanation:
The maximum payment reduction under the Hospital Readmissions Reduction Program is 3%. CMS expresses this through a payment adjustment factor ranging from 1.0, indicating no reduction, to 0.97, representing the maximum 3% reduction.
The HRRP links Medicare payment to excess readmission performance for specified clinical populations.
CMS applies the resulting adjustment to applicable Medicare fee-for-service base operating DRG payments.
This program should not be confused with other Medicare hospital quality-payment initiatives. The HAC Reduction Program imposes a 1% reduction on hospitals in the worst-performing quartile, while Hospital Value-Based Purchasing uses a 2% reduction-and-redistribution mechanism.
CMS's FY 2026 IPPS final rule also finalized changes to HRRP methodology that begin with the FY 2027 program year, including incorporation of Medicare Advantage data into the six readmission measures and shortening the applicable performance period from three years to two.
For CDI, the central obligation remains ensuring that the clinical record accurately portrays patient severity, conditions treated, discharge circumstances, and comorbid disease burden.
CCDS Reference Topics: HRRP; readmission measures; quality reimbursement; payment adjustments; risk adjustment.
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NEW QUESTION # 127
Two diagnoses both meet the definition of principal diagnosis and either could appropriately be sequenced first under the circumstances of admission. No specific sequencing instruction directs otherwise. Which rule applies?
Answer: A
Explanation:
When two diagnoses equally meet the definition of principal diagnosis, either condition may be sequenced first when the circumstances of admission, diagnostic workup, and treatment equally support both and no specific coding guideline, tabular instruction, or other sequencing rule directs otherwise.
The principal diagnosis cannot be selected based on which option generates higher payment. Financial outcome is not a legitimate sequencing criterion.
Likewise, chronological age of the diagnosis does not determine principal-diagnosis status. The principal diagnosis is established after study as the condition chiefly responsible for occasioning the admission.
A CDI query may be appropriate when the documentation does not actually establish whether both diagnoses equally occasioned the admission. However, querying simply because one sequencing choice would produce a more favorable MS-DRG is inappropriate.
This scenario tests the distinction between valid coding flexibility and improper reimbursement-driven documentation practices. CDI professionals must understand coding conventions well enough to avoid unnecessary queries while recognizing genuine ambiguity that requires provider clarification.
The FY 2026 MS-DRG grouper and Definitions Manual published by CMS provide the applicable grouper logic for the current fiscal year.
CCDS Reference Topics: Principal diagnosis; equally qualifying diagnoses; sequencing; ethical reimbursement practice.
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NEW QUESTION # 128
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: C
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 # 129
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