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| Section | Weight | Objectives |
|---|---|---|
| Topic 1: Anatomy and physiology, pathophysiology, pharmacology, and medical terminology | 19.17% | - Diseases and disorders of the skin, subcutaneous tissue, and breast - Injuries, poisonings, and toxic effects of drugs - Diagnostic tests as clinical indicators - Medications as clinical indicators - Infectious and parasitic diseases - Myeloproliferative diseases and disorders and poorly differentiated neoplasms - Diseases and disorders of the respiratory system - Standard medical abbreviations - Diseases and disorders of the blood and blood-forming organs and immunological disorders - Diseases and disorders of the hepatobiliary system - Diseases and disorders of the digestive system - Diseases and disorders of the kidney and urinary tract - Clinical indicators and query opportunities by Major Diagnostic Category - Diseases and disorders of the nervous system - Diseases and disorders of the circulatory system - Alcohol/drug use and alcohol/drug-induced organic brain disorders - Diseases and disorders of the musculoskeletal system - Mental diseases and disorders - Endocrine, nutritional, and metabolic diseases and disorders - HIV infections - Pharmaceuticals and disease processes |
| Topic 2: Communication skills | 9.17% | - Roles and responsibilities of coders working with CDI departments - Reconciling CDI working DRGs with final coded DRGs - Roles and responsibilities of CDI specialists - Effective and non-confrontational physician communication - Verbal versus written physician communication - Physician education forms and tools - Educational presentations for healthcare departments and administration |
| Topic 3: Healthcare facility CDI program analysis | 8.33% | - Severity of illness and risk of mortality - PEPPER data - CDI program forecasting - Tracking and trending physician, department, and hospital performance - Hospital Value-Based Purchasing measures - Case mix index (CMI) - High-frequency DRGs - CC/MCC capture - CDI specialist productivity metrics - Basic computer and software application skills - Publicly reported data - Physician performance measurement - Patient Safety Indicators - Provider response rates - Hospital-specific financial data |
| Topic 4: Professionalism, ethics, and compliance | 9.17% | - Medical record confidentiality - Potential DRG creep - CDI department goals beyond reimbursement - Compliance risks indicated by PEPPER - Leading queries - DRG compliance initiatives |
| Topic 5: Medical record documentation | 19.17% | - Addressing diagnoses without clinical support - Translating clinical indicators into compliant queries - Documentation requiring clarification - ACDIS/AHIMA Guidelines for Achieving a Compliant Query Practice - Health record elements used for diagnosis and procedure code assignment - Physician query formats - Types of physician queries - Situations in which queries are not appropriate - Compliant and noncompliant queries - When a physician query is warranted - Provider role and diagnosis code assignment - Clinical indicators |
| Topic 6: Impact of reportable diagnoses on quality of care | 8.33% | - Hospital Inpatient Quality Reporting Program - Documentation and code assignment impact on mortality index - Healthcare-associated infections and complication codes - Hospital-Acquired Condition Reduction Program - Mortality reviews and observed/expected ratios - Quality data from record abstraction and claims data - Coded data elements affecting Patient Safety Indicators - 30-day mortality measures - CDI impact on Hospital Value-Based Purchasing - Patient Safety Indicators - Hospital Value-Based Purchasing - Hospital Readmissions Reduction Program |
| Topic 7: Official Guidelines for Coding and Reporting | 14.17% | - Secondary diagnosis assignment - Coding guidelines for principal diagnosis selection - Official Guidelines for Coding and Reporting updates - Present on admission indicators - Principal diagnosis assignment - Discharge dispositions and transfers - Working DRG assignment for multiple diagnoses - Hospital-acquired conditions - AHA Coding Clinic |
| Topic 8: Healthcare regulations, reimbursement, and documentation requirements related to the IPPS | 12.5% | - Principal diagnosis and medical necessity - Case mix index (CMI) - Inpatient admission criteria and CMS Two-Midnight Rule - Documentation and medical necessity of setting - Coding and billing practices vulnerable to denial - Documentation impact on IPPS reimbursement - Major complication/comorbidity (MCC) - IPPS and its updates and revisions - Medical staff and clinical staff documentation responsibilities - Medicare contractors and their impact on CDI - Complication/comorbidity (CC) - Medicare Severity Diagnosis Related Groups (MS-DRGs) |
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NEW QUESTION # 49
A patient undergoes colorectal surgery. On postoperative day 2, the physician documents "ileus." The record shows absent bowel sounds and abdominal distention, but the surgeon also states that delayed bowel function is expected at this stage of recovery. Which action is MOST appropriate?
Answer: C
Explanation:
The record contains uncertainty regarding whether the documented ileus represents expected postoperative physiology or a clinically significant complication, making provider clarification appropriate.
Temporary impairment of gastrointestinal motility is common following abdominal surgery. Therefore, the mere occurrence of an ileus after surgery does not automatically establish a complication of care. Conversely, prolonged or clinically significant postoperative ileus requiring substantial treatment, extended hospitalization, nasogastric decompression, or other interventions may warrant distinct documentation.
The CDI specialist must not infer the complication relationship solely from timing. The Official Guidelines emphasize that a condition occurring after medical or surgical care is not automatically classified as a complication; appropriate provider documentation of the relationship and clinical significance is required where applicable.
Option C is also incorrect because postoperative ileus can be a reportable condition when clinically significant and appropriately documented. Option D substitutes a separate diagnosis without provider support.
The query should provide relevant duration, symptoms, imaging, diet status, nasogastric tube use, treatment, and expected postoperative course while allowing the surgeon to characterize the condition.
CCDS Reference Topics: Postoperative ileus; complications of care; postoperative documentation; clinical clarification.
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NEW QUESTION # 50
A physician documents acute kidney injury. The patient's creatinine is 0.8 mg/dL on admission, 0.9 mg/dL the following day, and 0.8 mg/dL at discharge. Urine output remains normal and no renal treatment is provided.
What is the BEST CDI action?
Answer: C
Explanation:
A clinical validation query is appropriate because the documented diagnosis appears inconsistent with the available clinical evidence. The creatinine values remain essentially unchanged, urine output is normal, and there is no apparent treatment or monitoring consistent with acute renal dysfunction.
The CDI specialist cannot simply delete the diagnosis because providers are responsible for establishing diagnoses. Conversely, a diagnosis should not automatically be accepted when substantial clinical evidence raises a legitimate question about its validity.
A compliant query would present the documented AKI together with the pertinent renal findings and request clarification. The provider could confirm AKI and provide supporting clinical reasoning, revise the diagnosis, state that it was ruled out, or document another condition.
Assigning chronic kidney disease would be equally inappropriate because CKD requires evidence of chronic kidney abnormality and cannot be inferred from these laboratory values.
The August 2026 ACDIS/AHIMA query guidance supersedes prior versions and remains the foundational standard for clinical validation and documentation clarification.
Clinical validation protects data integrity because diagnoses influence reimbursement, quality reporting, severity measurement, utilization analysis, and downstream patient information.
CCDS Reference Topics: Clinical validation; AKI; unsupported diagnoses; provider clarification; compliance.
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NEW QUESTION # 51
A patient underwent open small bowel resection with anastomosis for colon cancer. The physician notes,
"Post-op ileus, awaiting return of bowel function." Which of the following actions should a CDI specialist take FIRST?
Answer: A
Explanation:
The phrase "post-op ileus" establishes that the ileus occurred after surgery, but it does not necessarily establish that the ileus represents a reportable surgical complication rather than an expected transient consequence of abdominal surgery. The relationship and clinical significance therefore require clarification.
ICD-10-CM guidance on complications of care states that not every condition occurring during or following surgery is automatically classified as a complication. Code assignment depends on provider documentation establishing the relationship between the condition and the care or procedure, and the documentation must support clinical significance. When that relationship is unclear, the provider should be queried.
Assigning a complication code immediately would therefore be premature. Likewise, simply coding postoperative ileus without resolving whether it represents expected postoperative physiology or a clinically significant complication could misrepresent the episode.
Escalation to a physician advisor or CDI manager is unnecessary as the first action because this is a standard documentation-clarification issue that can be addressed directly through a compliant provider query.
CCDS Reference Topics: Official Guidelines-complications of care; medical record documentation; compliant provider clarification.
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NEW QUESTION # 52
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 # 53
A patient presents with crushing substernal chest pain, diaphoresis, ST-segment depression, and a significant rise and fall in cardiac troponin. The cardiologist documents acute coronary syndrome but does not specify the final diagnosis. Which clarification is MOST clinically appropriate?
Answer: C
Explanation:
The clinical picture presents an appropriate opportunity to clarify whether the patient has NSTEMI, unstable angina, or another acute coronary diagnosis.
A significant rise and/or fall in cardiac troponin consistent with acute myocardial injury, together with ischemic symptoms and ECG abnormalities, strongly raises concern for acute myocardial infarction. In contrast, unstable angina generally refers to ischemia without the biomarker evidence required for myocardial infarction.
Nevertheless, CDI should not make the diagnosis independently. Troponin elevations can occur in multiple conditions, including myocarditis, pulmonary embolism, sepsis, tachyarrhythmia, renal disease, and other forms of myocardial injury.
Therefore, the cardiologist should be asked to clarify the final diagnosis based on the complete clinical evaluation.
GERD, chronic stable angina, and old MI do not adequately reflect the acute findings described.
For CCDS preparation, cardiovascular questions frequently require distinguishing symptoms from established diagnoses and understanding the clinical indicators associated with NSTEMI, STEMI, type 2 MI, and other myocardial injury categories.
The ACDIS candidate handbook identifies anatomy, physiology, pharmacology, pathophysiology, and clinical record analysis as essential examination competencies.
CCDS Reference Topics: NSTEMI; acute coronary syndrome; troponin; myocardial ischemia; diagnostic clarification.
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NEW QUESTION # 54
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