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| Section | Weight | Objectives |
|---|---|---|
| Topic 1: Impact of reportable diagnoses on quality of care | 8.33% | - Hospital-Acquired Condition Reduction Program - Healthcare-associated infections and complication codes - Mortality reviews and observed/expected ratios - Quality data from record abstraction and claims data - CDI impact on Hospital Value-Based Purchasing - Hospital Inpatient Quality Reporting Program - Hospital Readmissions Reduction Program - Patient Safety Indicators - Coded data elements affecting Patient Safety Indicators - 30-day mortality measures - Documentation and code assignment impact on mortality index - Hospital Value-Based Purchasing |
| Topic 2: Communication skills | 9.17% | - Roles and responsibilities of coders working with CDI departments - Physician education forms and tools - Verbal versus written physician communication - Roles and responsibilities of CDI specialists - Educational presentations for healthcare departments and administration - Effective and non-confrontational physician communication - Reconciling CDI working DRGs with final coded DRGs |
| Topic 3: Anatomy and physiology, pathophysiology, pharmacology, and medical terminology | 19.17% | - Myeloproliferative diseases and disorders and poorly differentiated neoplasms - Diseases and disorders of the respiratory system - Injuries, poisonings, and toxic effects of drugs - Medications as clinical indicators - Clinical indicators and query opportunities by Major Diagnostic Category - Diseases and disorders of the digestive system - Diagnostic tests as clinical indicators - Mental diseases and disorders - Diseases and disorders of the circulatory system - Diseases and disorders of the musculoskeletal system - Standard medical abbreviations - Infectious and parasitic diseases - Diseases and disorders of the kidney and urinary tract - Endocrine, nutritional, and metabolic diseases and disorders - Diseases and disorders of the hepatobiliary system - Diseases and disorders of the nervous system - Diseases and disorders of the skin, subcutaneous tissue, and breast - Alcohol/drug use and alcohol/drug-induced organic brain disorders - Pharmaceuticals and disease processes - HIV infections - Diseases and disorders of the blood and blood-forming organs and immunological disorders |
| Topic 4: Professionalism, ethics, and compliance | 9.17% | - Leading queries - Potential DRG creep - Compliance risks indicated by PEPPER - Medical record confidentiality - CDI department goals beyond reimbursement - DRG compliance initiatives |
| Topic 5: Medical record documentation | 19.17% | - Health record elements used for diagnosis and procedure code assignment - Situations in which queries are not appropriate - ACDIS/AHIMA Guidelines for Achieving a Compliant Query Practice - Clinical indicators - When a physician query is warranted - Documentation requiring clarification - Provider role and diagnosis code assignment - Compliant and noncompliant queries - Addressing diagnoses without clinical support - Translating clinical indicators into compliant queries - Types of physician queries - Physician query formats |
| Topic 6: Healthcare regulations, reimbursement, and documentation requirements related to the IPPS | 12.5% | - Medicare Severity Diagnosis Related Groups (MS-DRGs) - Medicare contractors and their impact on CDI - Coding and billing practices vulnerable to denial - Documentation and medical necessity of setting - IPPS and its updates and revisions - Documentation impact on IPPS reimbursement - Principal diagnosis and medical necessity - Medical staff and clinical staff documentation responsibilities - Complication/comorbidity (CC) - Major complication/comorbidity (MCC) - Case mix index (CMI) - Inpatient admission criteria and CMS Two-Midnight Rule |
| Topic 7: Healthcare facility CDI program analysis | 8.33% | - Hospital Value-Based Purchasing measures - Hospital-specific financial data - CC/MCC capture - CDI program forecasting - Basic computer and software application skills - High-frequency DRGs - Provider response rates - PEPPER data - Patient Safety Indicators - Physician performance measurement - Tracking and trending physician, department, and hospital performance - Case mix index (CMI) - Publicly reported data - CDI specialist productivity metrics - Severity of illness and risk of mortality |
| Topic 8: Official Guidelines for Coding and Reporting | 14.17% | - Principal diagnosis assignment - Present on admission indicators - AHA Coding Clinic - Hospital-acquired conditions - Working DRG assignment for multiple diagnoses - Discharge dispositions and transfers - Coding guidelines for principal diagnosis selection - Secondary diagnosis assignment - Official Guidelines for Coding and Reporting updates |
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NEW QUESTION # 82
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: C
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 # 83
Which of the following programs specifically reduces applicable Medicare payments by 1% for hospitals in the worst-performing quartile based on hospital-acquired-condition measures?
Answer: D
Explanation:
The Hospital-Acquired Condition Reduction Program (HACRP) imposes a 1% reduction in applicable Medicare fee-for-service payments on subsection (d) hospitals ranking in the worst-performing quartile based on the Total HAC Score.
For the current program, CMS uses six measures: the CMS Patient Safety and Adverse Events Composite (PSI 90) and five healthcare-associated infection measures-CLABSI, CAUTI, specified surgical-site infection, MRSA bacteremia, and C. difficile infection.
HACRP must be distinguished from the separate DRA Hospital-Acquired Condition/Present-on-Admission payment provision. CMS explicitly states that these are different programs.
Hospital Value-Based Purchasing also links quality performance with hospital payment, but its structure is different: it is funded through a 2% reduction of participating hospitals' base operating DRG payments that is redistributed through value-based incentives.
For CDI professionals, accurate clinical documentation helps ensure that quality data appropriately represent the patient's condition and hospital course. CDI should not attempt to suppress valid complications or create unsupported comorbidities to change quality performance.
CCDS Reference Topics: HACRP; PSI 90; HAIs; quality reimbursement; CMS quality programs.
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NEW QUESTION # 84
A CDI program is piloting a new query form to better capture the documentation of pneumonia specificity.
Which of the following would be the BEST indicator to determine the effectiveness of the query form?
Answer: D
Explanation:
The most meaningful indicator is an increased volume of appropriately supported cases grouping to respiratory infection DRGs. The stated purpose of the pilot is not merely to obtain more physician responses; it is specifically to improve documentation of the type or etiology of pneumonia.
When providers document clinically supported pneumonia specificity-for example, an identified bacterial etiology or another qualifying respiratory infection-the coded case may move from a less specific/simple pneumonia grouping into a respiratory infections and inflammations DRG family, depending on the final diagnoses and grouper logic. A trend toward the expected DRG distribution can therefore demonstrate that the form is accomplishing its documentation objective.
Provider response and agreement rates are valuable CDI process metrics, but neither proves that useful specificity was obtained. A physician could respond to every query without adding meaningful diagnostic detail. Likewise, an increase in simple pneumonia DRGs would suggest that the intended specificity is not being captured effectively.
A robust CDI analysis should also verify that any DRG shift reflects clinically valid documentation rather than query pressure or reimbursement-oriented behavior.
CCDS Reference Topics: CDI metrics; query effectiveness; pneumonia specificity; MS-DRG trend analysis.
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NEW QUESTION # 85
A CDI program plans to develop a policy for addressing diagnoses that require clinical validation. According to the Guidelines for Achieving a Compliant Query Practice, which of the following should be addressed in the policy?
Answer: D
Explanation:
A compliant clinical-validation process should include a defined escalation process. The AHIMA/ACDIS query guidance specifically recommends organizational query policies that address escalation when a query remains unanswered or when documentation and clinical-validation concerns cannot be resolved through the ordinary workflow. Escalation may involve CDI or coding leadership, a physician advisor, the chief medical officer, or other designated personnel according to organizational policy.
Option A is inappropriate because simply coding every documented diagnosis without addressing significant clinical-support concerns undermines data integrity and increases denial and compliance risk. Option B is also too absolute. Coding professionals cannot independently substitute their clinical judgment for that of the responsible provider; unclear or potentially unsupported diagnoses should be addressed through an established clarification and validation process. Option D is incorrect because queries may appropriately occur concurrently or retrospectively depending on the circumstances and organizational workflow.
The goal of clinical validation is not to force removal or confirmation of a diagnosis. It is to ensure that the provider has an opportunity to clarify whether the diagnosis accurately represents the patient's clinical condition and to document supporting reasoning where appropriate.
CCDS Reference Topics: Professionalism, ethics, and compliance; clinical validation; compliant query policies; escalation procedures.
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NEW QUESTION # 86
The attending physician documents "severe protein-calorie malnutrition." The dietitian's assessment documents normal nutritional intake, stable body weight, no fat loss, and no muscle wasting. What should the CDI specialist do?
Answer: A
Explanation:
This is an appropriate clinical validation query because the provider has documented a diagnosis while the available clinical information appears inconsistent with that diagnosis.
The CDI specialist should not automatically accept every documented diagnosis when substantial contradictory clinical evidence exists. Conversely, CDI cannot independently delete the physician's diagnosis or replace the physician's clinical judgment.
The query should objectively identify the documented severe malnutrition and relevant contradictory findings-for example, stable weight, adequate nutritional intake, and absence of documented muscle or fat loss-and ask the provider to clarify whether severe malnutrition remains clinically appropriate, whether another nutritional condition better describes the patient, whether the diagnosis has been ruled out, or whether additional clinical reasoning supports it.
The query must remain neutral and should not mention the MCC status or potential reimbursement effect of severe malnutrition.
The August 2026 ACDIS/AHIMA compliant-query guidance supersedes previous editions and is the current foundational standard for compliant documentation clarification.
CCDS Reference Topics: Clinical validation; malnutrition; conflicting clinical indicators; compliant queries; documentation integrity.
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NEW QUESTION # 87
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