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| Section | Weight | Objectives |
|---|---|---|
| Topic 1: Medical record documentation | 19.17% | - ACDIS/AHIMA Guidelines for Achieving a Compliant Query Practice - Addressing diagnoses without clinical support - Compliant and noncompliant queries - Health record elements used for diagnosis and procedure code assignment - When a physician query is warranted - Physician query formats - Documentation requiring clarification - Situations in which queries are not appropriate - Clinical indicators - Provider role and diagnosis code assignment - Types of physician queries - Translating clinical indicators into compliant queries |
| Topic 2: Healthcare regulations, reimbursement, and documentation requirements related to the IPPS | 12.5% | - Principal diagnosis and medical necessity - Documentation and medical necessity of setting - Complication/comorbidity (CC) - Coding and billing practices vulnerable to denial - Medical staff and clinical staff documentation responsibilities - Major complication/comorbidity (MCC) - Medicare contractors and their impact on CDI - Documentation impact on IPPS reimbursement - Medicare Severity Diagnosis Related Groups (MS-DRGs) - Inpatient admission criteria and CMS Two-Midnight Rule - IPPS and its updates and revisions - Case mix index (CMI) |
| Topic 3: Communication skills | 9.17% | - Educational presentations for healthcare departments and administration - Roles and responsibilities of CDI specialists - Reconciling CDI working DRGs with final coded DRGs - Effective and non-confrontational physician communication - Verbal versus written physician communication - Physician education forms and tools - Roles and responsibilities of coders working with CDI departments |
| Topic 4: Professionalism, ethics, and compliance | 9.17% | - Leading queries - Medical record confidentiality - Potential DRG creep - DRG compliance initiatives - CDI department goals beyond reimbursement - Compliance risks indicated by PEPPER |
| Topic 5: Healthcare facility CDI program analysis | 8.33% | - Publicly reported data - CDI program forecasting - Physician performance measurement - Patient Safety Indicators - Basic computer and software application skills - Hospital Value-Based Purchasing measures - Hospital-specific financial data - CDI specialist productivity metrics - Severity of illness and risk of mortality - CC/MCC capture - PEPPER data - High-frequency DRGs - Provider response rates - Tracking and trending physician, department, and hospital performance - Case mix index (CMI) |
| Topic 6: Official Guidelines for Coding and Reporting | 14.17% | - Hospital-acquired conditions - AHA Coding Clinic - Secondary diagnosis assignment - Principal diagnosis assignment - Present on admission indicators - Discharge dispositions and transfers - Coding guidelines for principal diagnosis selection - Official Guidelines for Coding and Reporting updates - Working DRG assignment for multiple diagnoses |
| Topic 7: Anatomy and physiology, pathophysiology, pharmacology, and medical terminology | 19.17% | - Diseases and disorders of the digestive system - HIV infections - Myeloproliferative diseases and disorders and poorly differentiated neoplasms - Alcohol/drug use and alcohol/drug-induced organic brain disorders - Clinical indicators and query opportunities by Major Diagnostic Category - Diseases and disorders of the nervous system - Diseases and disorders of the skin, subcutaneous tissue, and breast - Mental diseases and disorders - Infectious and parasitic diseases - Pharmaceuticals and disease processes - Endocrine, nutritional, and metabolic diseases and disorders - Diagnostic tests as clinical indicators - Diseases and disorders of the circulatory system - Standard medical abbreviations - Medications as clinical indicators - Injuries, poisonings, and toxic effects of drugs - Diseases and disorders of the hepatobiliary system - Diseases and disorders of the musculoskeletal system - Diseases and disorders of the blood and blood-forming organs and immunological disorders - Diseases and disorders of the respiratory system - Diseases and disorders of the kidney and urinary tract |
| Topic 8: Impact of reportable diagnoses on quality of care | 8.33% | - Coded data elements affecting Patient Safety Indicators - Hospital Value-Based Purchasing - Hospital Inpatient Quality Reporting Program - Patient Safety Indicators - CDI impact on Hospital Value-Based Purchasing - Hospital-Acquired Condition Reduction Program - Healthcare-associated infections and complication codes - Quality data from record abstraction and claims data - Documentation and code assignment impact on mortality index - Hospital Readmissions Reduction Program - 30-day mortality measures - Mortality reviews and observed/expected ratios |
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NEW QUESTION # 36
A patient is admitted with fever and weakness. On hospital day 3, final blood cultures identify an infection that the physician documents was present at the time of admission. Which statement about present-on- admission status is MOST accurate?
Answer: D
Explanation:
A condition can be assigned present-on-admission status even when the definitive diagnosis is not made until later in the hospitalization. POA refers to whether the condition was present at the time the order for inpatient admission occurred, not the calendar date on which diagnostic confirmation became available.
This distinction is particularly relevant for infections, malignancies, fractures, acute vascular events, and other conditions whose definitive identification may require cultures, pathology, imaging, or additional diagnostic testing.
Therefore, a blood culture finalized on hospital day 3 does not automatically make the infection hospital acquired. The clinical record and provider documentation must establish whether the disease process was present at admission.
POA assignment applies to applicable principal and secondary diagnoses, not only the principal diagnosis.
CDI specialists should recognize unclear timing as a potential clarification opportunity because POA status can affect CMS Hospital-Acquired Condition payment logic and quality reporting.
The CCDS content outline expressly includes the basics of POA assignment and its impact on payment, as well as identification of CMS HACs.
CCDS Reference Topics: Present on admission; diagnosis timing; HACs; inpatient coding; quality reporting.
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NEW QUESTION # 37
CMS identifies the complete logic used to assign inpatient cases to MS-DRGs in which FY 2026 resource?
Answer: A
Explanation:
The ICD-10 MS-DRG Definitions Manual contains the detailed grouper logic CMS uses for MS-DRG assignment. CMS states that the FY 2026 Definitions Manual files provide the complete documentation of ICD-10 MS-DRG grouper logic.
The manual organizes MS-DRGs by Major Diagnostic Category and includes the principal diagnoses, procedures, MCC/CC structure, exclusions, and other logic needed to understand how cases group.
As of September 2026, CMS identifies FY 2026 Version 43.1 as effective for discharges from April 1 through September 30, 2026. Version 44 begins October 1, 2026 for FY 2027.
The Physician Fee Schedule governs professional services and does not define inpatient MS-DRGs. HCAHPS concerns patient-experience measurement, while the National Correct Coding Initiative focuses primarily on coding edits designed to prevent inappropriate code combinations in other reimbursement contexts.
CDI specialists do not need to memorize every grouper pathway, but they should understand how principal diagnosis, secondary conditions, procedures, and CC/MCC classifications interact to determine the working and final MS-DRG.
CCDS Reference Topics: MS-DRG Definitions Manual; grouper logic; IPPS; current fiscal-year resources.
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NEW QUESTION # 38
A patient is admitted with hypertension and acute systolic heart failure. The provider does not explicitly link the two conditions and does not state that they are unrelated. Which coding principle applies?
Answer: D
Explanation:
ICD-10-CM presumes a causal relationship between hypertension and qualifying heart disease, including heart failure, because the conditions are linked under "hypertension, with" in the Alphabetic Index. The presumed relationship applies unless the provider clearly documents that the heart disease is unrelated to hypertension.
Accordingly, hypertensive heart disease is coded using the appropriate I11.- category, with an additional I50.- code identifying the specific type and acuity of heart failure.
This convention differs from conditions for which ICD-10-CM does not provide a presumed causal link. In those circumstances, provider documentation must explicitly establish the relationship.
The CDI specialist therefore should not routinely query merely to obtain wording such as "hypertensive heart failure" when both hypertension and a qualifying heart-failure diagnosis are already documented and no statement says they are unrelated.
However, CDI may still need clarification when heart-failure type or acuity is incomplete, documentation is contradictory, or the physician expressly disputes a hypertensive relationship.
Recognizing these classification-based presumptions reduces unnecessary queries and supports accurate working-code and MS-DRG assignment.
CCDS Reference Topics: Hypertensive heart disease; heart failure; presumed relationships; coding conventions; query necessity.
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NEW QUESTION # 39
The MOST important factor influencing a hospital's ability to capture the most accurate MS-DRG involves:
Answer: B
Explanation:
Complete clinical documentation is the foundation of accurate MS-DRG assignment. The coding process translates provider documentation into ICD-10-CM and ICD-10-PCS codes, and those codes drive the MS- DRG grouper. If the record does not accurately capture the principal diagnosis, secondary diagnoses, acuity, etiologies, complications, procedures, and clinically relevant relationships, the resulting MS-DRG may not accurately represent the patient's hospitalization.
CMS explains that MS-DRG assignment depends on factors including diagnoses, procedures, complicating conditions, age, sex, and discharge status. Each resulting MS-DRG has a payment weight representing relative resource requirements.
POA documentation is important, particularly for HAC payment logic, but it is only one component of overall documentation completeness. Quality indicators and patient-satisfaction information serve other important organizational purposes but do not substitute for complete provider documentation when grouping the inpatient claim.
The role of CDI is therefore broader than capturing CCs or MCCs. CDI professionals work to ensure that the entire medical record provides a precise clinical description of the patient and services rendered, allowing coding, quality reporting, risk adjustment, utilization review, and reimbursement to be based on the same accurate clinical story.
CCDS Reference Topics: Documentation integrity; MS-DRG assignment; principal/secondary diagnoses; CDI fundamentals.
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NEW QUESTION # 40
A CDI specialist is asked to develop an educational presentation for a physician group on how documentation affects patient outcome measures within the CDI department. Which of the following is the MOST important measure to include when developing the presentation?
Answer: B
Explanation:
The mortality ratio is the option most directly associated with patient outcome measurement and risk-adjusted quality reporting. Although the question uses the phrase expected/observed mortality ratio, mortality analytics are frequently expressed operationally as an observed-to-expected (O/E) mortality ratio. Documentation affects the expected component because severity-of-illness and risk-of-mortality models depend substantially on accurately reported diagnoses and comorbid conditions.
If important acute or chronic conditions are not documented or are insufficiently specified, coded data may portray a patient as less severely ill than the clinical reality. The expected mortality calculated by a risk- adjustment model may therefore be lower, potentially making actual mortality performance appear less favorable. This makes mortality analysis particularly useful when teaching physicians why documentation affects quality measures independently of reimbursement.
CC/MCC capture is useful for examining documentation and reimbursement performance but is not itself an outcome measure. Monthly review volume is a productivity metric, while CDI/coder agreement evaluates internal process performance.
The CCDS examination content specifically includes mortality reviews, interpretation of observed/expected ratios, severity of illness, risk of mortality, and documentation effects on publicly reported quality data.
CCDS Reference Topics: Impact of reportable diagnoses on quality of care; SOI/ROM; mortality index; physician education.
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NEW QUESTION # 41
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