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| Section | Weight | Objectives |
|---|---|---|
| Topic 1: Healthcare regulations, reimbursement, and documentation requirements related to the IPPS | 12.5% | - Major complication/comorbidity (MCC) - Principal diagnosis and medical necessity - Complication/comorbidity (CC) - Case mix index (CMI) - Medicare contractors and their impact on CDI - IPPS and its updates and revisions - Medicare Severity Diagnosis Related Groups (MS-DRGs) - Medical staff and clinical staff documentation responsibilities - Coding and billing practices vulnerable to denial - Documentation and medical necessity of setting - Documentation impact on IPPS reimbursement - Inpatient admission criteria and CMS Two-Midnight Rule |
| Topic 2: Official Guidelines for Coding and Reporting | 14.17% | - AHA Coding Clinic - Principal diagnosis assignment - Present on admission indicators - Coding guidelines for principal diagnosis selection - Official Guidelines for Coding and Reporting updates - Working DRG assignment for multiple diagnoses - Discharge dispositions and transfers - Secondary diagnosis assignment - Hospital-acquired conditions |
| Topic 3: Healthcare facility CDI program analysis | 8.33% | - Basic computer and software application skills - CDI specialist productivity metrics - Case mix index (CMI) - Publicly reported data - Hospital-specific financial data - Tracking and trending physician, department, and hospital performance - CC/MCC capture - CDI program forecasting - Hospital Value-Based Purchasing measures - Provider response rates - High-frequency DRGs - Physician performance measurement - Patient Safety Indicators - PEPPER data - Severity of illness and risk of mortality |
| Topic 4: Communication skills | 9.17% | - Physician education forms and tools - Effective and non-confrontational physician communication - Educational presentations for healthcare departments and administration - Roles and responsibilities of CDI specialists - Verbal versus written physician communication - Reconciling CDI working DRGs with final coded DRGs - Roles and responsibilities of coders working with CDI departments |
| Topic 5: Medical record documentation | 19.17% | - Documentation requiring clarification - Types of physician queries - When a physician query is warranted - Translating clinical indicators into compliant queries - Addressing diagnoses without clinical support - ACDIS/AHIMA Guidelines for Achieving a Compliant Query Practice - Situations in which queries are not appropriate - Clinical indicators - Compliant and noncompliant queries - Health record elements used for diagnosis and procedure code assignment - Provider role and diagnosis code assignment - Physician query formats |
| Topic 6: Professionalism, ethics, and compliance | 9.17% | - Compliance risks indicated by PEPPER - Potential DRG creep - DRG compliance initiatives - CDI department goals beyond reimbursement - Leading queries - Medical record confidentiality |
| Topic 7: Impact of reportable diagnoses on quality of care | 8.33% | - Hospital-Acquired Condition Reduction Program - Quality data from record abstraction and claims data - Healthcare-associated infections and complication codes - CDI impact on Hospital Value-Based Purchasing - Coded data elements affecting Patient Safety Indicators - 30-day mortality measures - Mortality reviews and observed/expected ratios - Hospital Readmissions Reduction Program - Hospital Inpatient Quality Reporting Program - Documentation and code assignment impact on mortality index - Patient Safety Indicators - Hospital Value-Based Purchasing |
| Topic 8: Anatomy and physiology, pathophysiology, pharmacology, and medical terminology | 19.17% | - HIV infections - Diseases and disorders of the respiratory system - Infectious and parasitic diseases - Clinical indicators and query opportunities by Major Diagnostic Category - Diseases and disorders of the skin, subcutaneous tissue, and breast - Alcohol/drug use and alcohol/drug-induced organic brain disorders - Diseases and disorders of the kidney and urinary tract - Diseases and disorders of the nervous system - Mental diseases and disorders - Pharmaceuticals and disease processes - Diseases and disorders of the digestive system - Diseases and disorders of the blood and blood-forming organs and immunological disorders - Diagnostic tests as clinical indicators - Endocrine, nutritional, and metabolic diseases and disorders - Diseases and disorders of the hepatobiliary system - Myeloproliferative diseases and disorders and poorly differentiated neoplasms - Injuries, poisonings, and toxic effects of drugs - Diseases and disorders of the musculoskeletal system - Standard medical abbreviations - Diseases and disorders of the circulatory system - Medications as clinical indicators |
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NEW QUESTION # 83
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?
Answer: B
Explanation:
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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NEW QUESTION # 84
A hospital's mortality report shows 125 observed deaths and 100 expected deaths. The observed-to-expected mortality ratio is 1.25. Which interpretation is MOST accurate?
Answer: B
Explanation:
An observed-to-expected mortality ratio is calculated by dividing observed deaths by expected deaths. Here,
125 divided by 100 equals 1.25. Therefore, observed deaths are 25% higher than the number predicted by the risk-adjustment model.
A ratio of 1.0 indicates observed mortality equals expected mortality. A value below 1.0 indicates fewer observed deaths than predicted, while a value above 1.0 indicates more observed deaths than predicted.
The CDI implication is important. Expected mortality is influenced by the patient's documented disease burden and other variables used by the applicable risk-adjustment methodology. If clinically significant conditions are underdocumented, the coded record may fail to represent the patient's actual severity, potentially reducing calculated expected mortality.
However, CDI should never seek diagnoses solely to improve a mortality ratio. Each diagnosis must be clinically supported and accurately documented. A high ratio can reflect multiple factors-including clinical outcomes, case mix, documentation, coding, data quality, or model characteristics-and should trigger multidisciplinary analysis rather than automatic querying.
ACDIS includes mortality and severity/risk adjustment within CCDS competency expectations.
CCDS Reference Topics: O/E mortality; risk adjustment; severity documentation; quality outcomes.
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NEW QUESTION # 85
Which of the following diagnoses is classified as a major complication/comorbidity (MCC) under the FY
2026 MS-DRG system?
Answer: A
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 # 86
A patient is admitted with pneumonia. On hospital day 3, the patient deteriorates and the physician documents that sepsis developed after admission as a consequence of the pneumonia. Which diagnosis is generally sequenced first?
Answer: B
Explanation:
When a patient is admitted with a localized infection and sepsis develops after admission, the localized infection is generally sequenced as the principal diagnosis, followed by the appropriate sepsis code.
The FY 2026 ICD-10-CM Official Guidelines explicitly distinguish this circumstance from cases in which both the localized infection and sepsis are present on admission. When sepsis develops only after admission, the localized infection responsible for the original hospitalization remains principal.
Therefore, pneumonia is sequenced first in this scenario.
If the patient subsequently develops acute organ dysfunction related to sepsis and the provider documents severe sepsis, additional severe-sepsis and organ-dysfunction codes are assigned as appropriate. The severe- sepsis code cannot itself serve as principal diagnosis.
This question demonstrates why CDI specialists must clarify timing. Simply seeing both "pneumonia" and
"sepsis" in a discharge summary is insufficient to determine correct sequencing when the onset relationship is unclear.
The POA status of sepsis also becomes relevant because documentation indicates that it developed after inpatient admission.
CCDS Reference Topics: Sepsis; pneumonia; sequencing; timing; POA; principal diagnosis.
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NEW QUESTION # 87
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?
Answer: A
NEW QUESTION # 88
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