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| Section | Weight | Objectives |
|---|---|---|
| Topic 1: Impact of reportable diagnoses on quality of care | 8.33% | - Documentation and code assignment impact on mortality index - Hospital Readmissions Reduction Program - Quality data from record abstraction and claims data - CDI impact on Hospital Value-Based Purchasing - Hospital Value-Based Purchasing - Patient Safety Indicators - Hospital-Acquired Condition Reduction Program - 30-day mortality measures - Healthcare-associated infections and complication codes - Hospital Inpatient Quality Reporting Program - Coded data elements affecting Patient Safety Indicators - Mortality reviews and observed/expected ratios |
| Topic 2: Anatomy and physiology, pathophysiology, pharmacology, and medical terminology | 19.17% | - Medications as clinical indicators - Pharmaceuticals and disease processes - Injuries, poisonings, and toxic effects of drugs - Diagnostic tests as clinical indicators - Infectious and parasitic diseases - Diseases and disorders of the nervous system - Diseases and disorders of the blood and blood-forming organs and immunological disorders - Endocrine, nutritional, and metabolic diseases and disorders - Diseases and disorders of the hepatobiliary system - Diseases and disorders of the circulatory system - Alcohol/drug use and alcohol/drug-induced organic brain disorders - HIV infections - Diseases and disorders of the skin, subcutaneous tissue, and breast - Diseases and disorders of the respiratory system - Myeloproliferative diseases and disorders and poorly differentiated neoplasms - Diseases and disorders of the kidney and urinary tract - Diseases and disorders of the musculoskeletal system - Diseases and disorders of the digestive system - Clinical indicators and query opportunities by Major Diagnostic Category - Standard medical abbreviations - Mental diseases and disorders |
| Topic 3: Official Guidelines for Coding and Reporting | 14.17% | - AHA Coding Clinic - Official Guidelines for Coding and Reporting updates - Present on admission indicators - Coding guidelines for principal diagnosis selection - Secondary diagnosis assignment - Working DRG assignment for multiple diagnoses - Discharge dispositions and transfers - Principal diagnosis assignment - Hospital-acquired conditions |
| Topic 4: Professionalism, ethics, and compliance | 9.17% | - Potential DRG creep - DRG compliance initiatives - Leading queries - CDI department goals beyond reimbursement - Compliance risks indicated by PEPPER - Medical record confidentiality |
| Topic 5: Communication skills | 9.17% | - Reconciling CDI working DRGs with final coded DRGs - Roles and responsibilities of coders working with CDI departments - Verbal versus written physician communication - Roles and responsibilities of CDI specialists - Physician education forms and tools - Effective and non-confrontational physician communication - Educational presentations for healthcare departments and administration |
| Topic 6: Medical record documentation | 19.17% | - Provider role and diagnosis code assignment - When a physician query is warranted - Documentation requiring clarification - Addressing diagnoses without clinical support - Clinical indicators - Situations in which queries are not appropriate - Translating clinical indicators into compliant queries - Compliant and noncompliant queries - Types of physician queries - ACDIS/AHIMA Guidelines for Achieving a Compliant Query Practice - Health record elements used for diagnosis and procedure code assignment - Physician query formats |
| Topic 7: Healthcare regulations, reimbursement, and documentation requirements related to the IPPS | 12.5% | - Inpatient admission criteria and CMS Two-Midnight Rule - Major complication/comorbidity (MCC) - Medicare Severity Diagnosis Related Groups (MS-DRGs) - Principal diagnosis and medical necessity - Coding and billing practices vulnerable to denial - IPPS and its updates and revisions - Documentation impact on IPPS reimbursement - Medicare contractors and their impact on CDI - Complication/comorbidity (CC) - Medical staff and clinical staff documentation responsibilities - Case mix index (CMI) - Documentation and medical necessity of setting |
| Topic 8: Healthcare facility CDI program analysis | 8.33% | - Physician performance measurement - CDI specialist productivity metrics - CDI program forecasting - Tracking and trending physician, department, and hospital performance - High-frequency DRGs - Patient Safety Indicators - Provider response rates - Severity of illness and risk of mortality - Basic computer and software application skills - Hospital Value-Based Purchasing measures - Publicly reported data - PEPPER data - CC/MCC capture - Case mix index (CMI) - Hospital-specific financial data |
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NEW QUESTION # 130
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 # 131
A patient's chest x-ray shows pulmonary vascular congestion and pleural effusions. These findings are most consistent with which of the following conditions?
Answer: B
Explanation:
Pulmonary vascular congestion accompanied by pleural effusions is classically associated with congestive heart failure, particularly left-sided or biventricular decompensation. Increased left-sided cardiac filling pressure raises pulmonary venous and capillary hydrostatic pressure, promoting interstitial and alveolar fluid accumulation. Fluid may also migrate into the pleural space, producing unilateral or bilateral pleural effusions.
Additional radiographic indicators of heart failure may include cardiomegaly, cephalization of pulmonary vessels, interstitial edema, Kerley B lines, perihilar alveolar opacities, and bilateral effusions. These findings should always be interpreted alongside symptoms and other clinical evidence such as dyspnea, orthopnea, edema, BNP/NT-proBNP, echocardiography, and response to diuretics.
COPD more commonly demonstrates hyperinflation, flattened diaphragms, and increased lucency rather than pulmonary vascular congestion. Cor pulmonale refers to right-sided cardiac dysfunction resulting from pulmonary disease and does not typically produce the classic pulmonary venous congestion pattern.
Pulmonary embolism may have a normal chest radiograph or nonspecific abnormalities, but pulmonary vascular congestion with effusions is not its characteristic pattern.
For CDI purposes, imaging provides a clinical indicator but does not independently establish the diagnosis or acuity of heart failure.
CCDS Reference Topics: Heart failure pathophysiology; chest radiography; clinical indicators; cardiopulmonary terminology.
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NEW QUESTION # 132
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 # 133
An arterial blood gas shows pH 7.24, PaCO# 72 mmHg, and HCO## 30 mEq/L in a patient with COPD and acute respiratory distress. Which acid-base abnormality is primarily demonstrated?
Answer: B
Explanation:
The arterial blood gas primarily demonstrates respiratory acidosis. The pH is significantly acidemic at 7.24, while PaCO# is markedly elevated at 72 mmHg. Because carbon dioxide acts as an acid through the carbonic acid buffering system, CO# retention lowers blood pH.
The bicarbonate of 30 mEq/L is mildly elevated, suggesting some renal compensation, which may occur in patients with chronic CO# retention from COPD. However, the substantial acidemia indicates that compensation is insufficient and an acute component may be present.
In a COPD patient with acute respiratory distress, such findings can create an appropriate clinical basis for clarification of acute or acute-on-chronic hypercapnic respiratory failure when other supporting indicators are present, such as worsening work of breathing, altered mental status, escalating oxygen needs, BiPAP, or intubation.
The CDI specialist should not independently equate every abnormal ABG with respiratory failure. The provider determines the clinical diagnosis.
Respiratory alkalosis would involve reduced PaCO#. Metabolic acidosis generally involves reduced bicarbonate as the primary disturbance, while metabolic alkalosis involves primary bicarbonate elevation with alkalemia.
CCDS Reference Topics: ABG interpretation; respiratory acidosis; hypercapnia; COPD; respiratory failure.
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NEW QUESTION # 134
The amount of the IPPS Indirect Medical Education Adjustment is determined by teaching intensity as measured by the hospital's number of residents compared to:
Answer: A
Explanation:
Medicare's Indirect Medical Education (IME) adjustment uses the hospital's resident-to-bed ratio as the principal measure of teaching intensity. CMS explains that the IME adjustment factor is calculated using a hospital's ratio of residents to beds. Therefore, the correct answer is inpatient beds.
IME is an additional IPPS payment intended to recognize the higher indirect patient-care costs associated with operating an approved teaching program. These costs are distinguished from Direct Graduate Medical Education payments, which reimburse qualifying direct costs associated with residency training.
The number of admissions is not the denominator in the IME teaching-intensity calculation. Likewise, emergency-department beds are not simply combined with inpatient beds for the standard resident-to-bed ratio, and disproportionate-share payment rates represent a separate IPPS adjustment related principally to hospitals caring for substantial numbers of low-income patients.
For the CCDS examination, the important distinction is that IPPS reimbursement involves more than the base MS-DRG payment. Adjustments may include IME, disproportionate-share hospital provisions, wage-index effects, outlier payments, and other statutory mechanisms.
CCDS Reference Topics: IPPS reimbursement; teaching hospitals; IME adjustment; resident-to-bed ratio.
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NEW QUESTION # 135
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