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| Section | Weight | Objectives |
|---|---|---|
| Topic 1: Healthcare facility CDI program analysis | 8.33% | - Patient Safety Indicators - Tracking and trending physician, department, and hospital performance - PEPPER data - Severity of illness and risk of mortality - Hospital Value-Based Purchasing measures - CC/MCC capture - Provider response rates - CDI program forecasting - Publicly reported data - CDI specialist productivity metrics - Physician performance measurement - Hospital-specific financial data - Case mix index (CMI) - High-frequency DRGs - Basic computer and software application skills |
| Topic 2: Communication skills | 9.17% | - Physician education forms and tools - Roles and responsibilities of coders working with CDI departments - Educational presentations for healthcare departments and administration - Effective and non-confrontational physician communication - Verbal versus written physician communication - Reconciling CDI working DRGs with final coded DRGs - Roles and responsibilities of CDI specialists |
| Topic 3: Official Guidelines for Coding and Reporting | 14.17% | - Official Guidelines for Coding and Reporting updates - Secondary diagnosis assignment - Coding guidelines for principal diagnosis selection - Present on admission indicators - Hospital-acquired conditions - Discharge dispositions and transfers - AHA Coding Clinic - Principal diagnosis assignment - Working DRG assignment for multiple diagnoses |
| Topic 4: Healthcare regulations, reimbursement, and documentation requirements related to the IPPS | 12.5% | - Inpatient admission criteria and CMS Two-Midnight Rule - Coding and billing practices vulnerable to denial - IPPS and its updates and revisions - Medicare Severity Diagnosis Related Groups (MS-DRGs) - Medicare contractors and their impact on CDI - Complication/comorbidity (CC) - Medical staff and clinical staff documentation responsibilities - Principal diagnosis and medical necessity - Major complication/comorbidity (MCC) - Documentation impact on IPPS reimbursement - Case mix index (CMI) - Documentation and medical necessity of setting |
| Topic 5: Medical record documentation | 19.17% | - Clinical indicators - Compliant and noncompliant queries - Health record elements used for diagnosis and procedure code assignment - Provider role and diagnosis code assignment - ACDIS/AHIMA Guidelines for Achieving a Compliant Query Practice - Translating clinical indicators into compliant queries - Addressing diagnoses without clinical support - Documentation requiring clarification - Physician query formats - When a physician query is warranted - Types of physician queries - Situations in which queries are not appropriate |
| Topic 6: Professionalism, ethics, and compliance | 9.17% | - DRG compliance initiatives - Potential DRG creep - Compliance risks indicated by PEPPER - Leading queries - Medical record confidentiality - CDI department goals beyond reimbursement |
| Topic 7: Anatomy and physiology, pathophysiology, pharmacology, and medical terminology | 19.17% | - Clinical indicators and query opportunities by Major Diagnostic Category - HIV infections - Diseases and disorders of the hepatobiliary system - Diseases and disorders of the kidney and urinary tract - Endocrine, nutritional, and metabolic diseases and disorders - Diagnostic tests as clinical indicators - Infectious and parasitic diseases - Standard medical abbreviations - Diseases and disorders of the digestive system - Diseases and disorders of the nervous system - Alcohol/drug use and alcohol/drug-induced organic brain disorders - Medications as clinical indicators - Diseases and disorders of the respiratory system - Diseases and disorders of the musculoskeletal system - Pharmaceuticals and disease processes - Mental diseases and disorders - Diseases and disorders of the blood and blood-forming organs and immunological disorders - Diseases and disorders of the circulatory system - Injuries, poisonings, and toxic effects of drugs - Myeloproliferative diseases and disorders and poorly differentiated neoplasms - Diseases and disorders of the skin, subcutaneous tissue, and breast |
| Topic 8: Impact of reportable diagnoses on quality of care | 8.33% | - Hospital Value-Based Purchasing - Patient Safety Indicators - 30-day mortality measures - Documentation and code assignment impact on mortality index - Quality data from record abstraction and claims data - Coded data elements affecting Patient Safety Indicators - Hospital Readmissions Reduction Program - Healthcare-associated infections and complication codes - Hospital Inpatient Quality Reporting Program - Hospital-Acquired Condition Reduction Program - CDI impact on Hospital Value-Based Purchasing - Mortality reviews and observed/expected ratios |
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NEW QUESTION # 78
During one month, a CDI department issued 400 queries. Providers responded to 360 of them. What was the provider query response rate?
Answer: D
Explanation:
Provider query response rate is calculated by dividing the number of answered queries by the total number of queries requiring a response, then multiplying by 100.
360 ÷ 400 × 100 = 90%.
Therefore, the provider response rate is 90%.
Response rate measures whether clinicians engage with documentation clarification requests. It should be distinguished from agreement rate, which measures how often the provider's response supports the diagnosis or clarification being considered. A physician can respond appropriately while disagreeing with the proposed diagnostic possibilities, so a lower agreement rate does not necessarily indicate poor engagement.
A CDI manager should also evaluate response timeliness, service-line patterns, unanswered-query aging, escalation frequency, and whether responses result in complete documentation.
A response rate should not be artificially increased by pressuring providers to choose a particular answer.
Current ACDIS/AHIMA guidance emphasizes a compliant clarification process that preserves independent provider judgment.
In mature CDI programs, metrics are best evaluated longitudinally rather than in isolation. Significant changes should be examined for workflow, staffing, education, electronic-query functionality, or physician- engagement factors.
CCDS Reference Topics: Query response rate; CDI metrics; provider engagement; program analysis; communication.
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NEW QUESTION # 79
A patient experienced a type 1 STEMI 10 days ago. The patient is readmitted and develops a new type 1 NSTEMI during the four-week acute myocardial infarction period. Which ICD-10-CM concept applies?
Answer: C
Explanation:
ICD-10-CM provides category I22 for a subsequent acute myocardial infarction occurring within four weeks-28 days-of an initial acute MI, when the qualifying MI types and circumstances meet the classification requirements.
The FY 2026 Official Guidelines specify that when a patient with a type 1 or unspecified acute MI experiences a new type 1 or unspecified MI within four weeks of the initial MI, a code from category I22 is used together with the appropriate I21 code. Sequencing depends on the circumstances of the encounter.
This rule requires care because type 2 MI and certain other myocardial infarction classifications do not follow the same I22 subsequent-MI logic. CDI specialists therefore need accurate documentation of MI type, anatomic location when applicable, timing, and whether the current event represents a genuinely new infarction rather than ongoing care for the original MI.
The prior STEMI does not become an "old MI" merely because the patient left the hospital; the ICD-10-CM acute MI period extends for four weeks from onset.
CCDS Reference Topics: Acute MI; subsequent MI; I21/I22; four-week rule; cardiovascular coding.
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NEW QUESTION # 80
Under the IPPS Post-Acute Care Transfer policy, which documentation element is particularly important because it can affect whether transfer-payment methodology applies?
Answer: A
Explanation:
Accurate discharge disposition is critical to application of the Post-Acute Care Transfer policy because the patient's destination after the acute inpatient stay can determine whether transfer-payment methodology applies.
Qualifying discharges to certain post-acute settings can be subject to transfer-payment rules when other criteria are met. These settings can include skilled nursing facilities and other specified post-acute arrangements, depending on applicable CMS requirements and the MS-DRG involved.
Therefore, an incorrectly documented discharge destination can affect reimbursement even when the diagnoses, procedures, and MS-DRG are otherwise accurate.
The PACT concept demonstrates why CDI and coding accuracy extend beyond diagnosis capture. The inpatient claim also relies on accurate demographic, procedural, discharge-status, and utilization information.
Dietary preference, physician experience, and the number of daily progress notes do not determine whether PACT methodology applies.
CDI specialists should recognize when conflicting documentation exists regarding whether a patient went home, to skilled nursing, rehabilitation, another acute facility, hospice, or another destination and collaborate with the appropriate departments to ensure the final record accurately reflects the actual disposition.
CCDS Reference Topics: PACT; discharge disposition; IPPS transfer rules; reimbursement; data integrity.
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NEW QUESTION # 81
A patient is admitted with sepsis due to osteomyelitis and evidence of organ failure. Which of the following is the correct principal diagnosis?
Answer: D
Explanation:
The underlying systemic infection/sepsis code is sequenced as the principal diagnosis when sepsis or severe sepsis is present on admission and is the condition chiefly responsible for admission. Therefore, sepsis is the correct selection from the available choices.
The presence of organ failure means the patient may also meet the documentation requirements for severe sepsis when the acute organ dysfunction is explicitly associated with the sepsis. However, the severe-sepsis code from subcategory R65.2- cannot be assigned as the principal diagnosis. The FY 2026 ICD-10-CM Official Guidelines require the underlying systemic infection first, followed by R65.2- and codes for the associated acute organ dysfunction.
Osteomyelitis represents the localized infection source, but when the reason for admission is sepsis associated with that localized infection, the systemic infection is sequenced first under the sepsis guidelines.
"Septicemia" should not be substituted for provider-documented sepsis.
The CDI specialist should also verify that the provider has clearly linked the organ failure to sepsis before severe-sepsis coding is applied.
CCDS Reference Topics: Sepsis sequencing; severe sepsis; principal diagnosis; localized infection.
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NEW QUESTION # 82
A hospital's case is assigned to an MS-DRG with a relative weight of 2.0000. What does the relative weight primarily indicate?
Answer: D
Explanation:
An MS-DRG relative weight represents relative expected resource consumption, not a direct severity score or mortality probability. Therefore, a relative weight of approximately 2.0 means the MS-DRG is associated with roughly twice the resource intensity of the average case represented by the standardized reference point.
CMS calculates and recalibrates MS-DRG relative weights using national hospital data as part of IPPS rate setting. The FY 2026 final-rule materials include the MS-DRG weighting factors as well as supporting cost data used in the relative-weight methodology.
Clinically complex cases often consume more resources, so relative weight may correlate with severity.
However, it is not equivalent to a patient's severity-of-illness score or risk-of-mortality score. Likewise, hospitals do not simply multiply their billed charges based on the DRG weight. IPPS payment involves the standardized amount plus various adjustments, including wage index and other applicable payment factors.
For CDI, accurate documentation matters because diagnoses and procedures drive MS-DRG assignment, and the assigned MS-DRG carries its specific relative weight.
CCDS Reference Topics: IPPS; MS-DRG relative weight; resource consumption; reimbursement methodology.
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NEW QUESTION # 83
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