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| Section | Weight | Objectives |
|---|---|---|
| Impact of reportable diagnoses on quality of care | 8.33% | - Coded data elements affecting Patient Safety Indicators - Documentation and code assignment impact on mortality index - 30-day mortality measures - Hospital Inpatient Quality Reporting Program - Mortality reviews and observed/expected ratios - Hospital-Acquired Condition Reduction Program - Patient Safety Indicators - CDI impact on Hospital Value-Based Purchasing - Quality data from record abstraction and claims data - Hospital Value-Based Purchasing - Hospital Readmissions Reduction Program - Healthcare-associated infections and complication codes |
| Medical record documentation | 19.17% | - When a physician query is warranted - Clinical indicators - Situations in which queries are not appropriate - Translating clinical indicators into compliant queries - Physician query formats - Addressing diagnoses without clinical support - ACDIS/AHIMA Guidelines for Achieving a Compliant Query Practice - Provider role and diagnosis code assignment - Compliant and noncompliant queries - Documentation requiring clarification - Types of physician queries - Health record elements used for diagnosis and procedure code assignment |
| Official Guidelines for Coding and Reporting | 14.17% | - Secondary diagnosis assignment - Coding guidelines for principal diagnosis selection - Discharge dispositions and transfers - Working DRG assignment for multiple diagnoses - AHA Coding Clinic - Principal diagnosis assignment - Hospital-acquired conditions - Official Guidelines for Coding and Reporting updates - Present on admission indicators |
| Healthcare facility CDI program analysis | 8.33% | - CDI specialist productivity metrics - Hospital-specific financial data - Hospital Value-Based Purchasing measures - PEPPER data - Publicly reported data - Provider response rates - Physician performance measurement - CC/MCC capture - Patient Safety Indicators - Tracking and trending physician, department, and hospital performance - High-frequency DRGs - Severity of illness and risk of mortality - Basic computer and software application skills - Case mix index (CMI) - CDI program forecasting |
| Healthcare regulations, reimbursement, and documentation requirements related to the IPPS | 12.5% | - Medicare Severity Diagnosis Related Groups (MS-DRGs) - Principal diagnosis and medical necessity - Medical staff and clinical staff documentation responsibilities - Medicare contractors and their impact on CDI - IPPS and its updates and revisions - Inpatient admission criteria and CMS Two-Midnight Rule - Documentation and medical necessity of setting - Complication/comorbidity (CC) - Major complication/comorbidity (MCC) - Case mix index (CMI) - Coding and billing practices vulnerable to denial - Documentation impact on IPPS reimbursement |
| Communication skills | 9.17% | - Educational presentations for healthcare departments and administration - Verbal versus written physician communication - Physician education forms and tools - Reconciling CDI working DRGs with final coded DRGs - Roles and responsibilities of CDI specialists - Roles and responsibilities of coders working with CDI departments - Effective and non-confrontational physician communication |
| Anatomy and physiology, pathophysiology, pharmacology, and medical terminology | 19.17% | - Diseases and disorders of the circulatory system - Standard medical abbreviations - Diseases and disorders of the skin, subcutaneous tissue, and breast - Medications as clinical indicators - Diseases and disorders of the hepatobiliary system - Diseases and disorders of the digestive system - Clinical indicators and query opportunities by Major Diagnostic Category - Pharmaceuticals and disease processes - Myeloproliferative diseases and disorders and poorly differentiated neoplasms - Endocrine, nutritional, and metabolic diseases and disorders - Diseases and disorders of the respiratory system - Diagnostic tests as clinical indicators - Diseases and disorders of the blood and blood-forming organs and immunological disorders - Injuries, poisonings, and toxic effects of drugs - HIV infections - Diseases and disorders of the nervous system - Diseases and disorders of the kidney and urinary tract - Alcohol/drug use and alcohol/drug-induced organic brain disorders - Infectious and parasitic diseases - Diseases and disorders of the musculoskeletal system - Mental diseases and disorders |
| Professionalism, ethics, and compliance | 9.17% | - Medical record confidentiality - Leading queries - Compliance risks indicated by PEPPER - CDI department goals beyond reimbursement - Potential DRG creep - DRG compliance initiatives |
>> ACDIS CCDS Zertifizierungsantworten <<
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97. Frage
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?
Antwort: C
Begründung:
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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98. Frage
A patient with COPD normally has a PaCO# of approximately 45 mmHg. The patient is admitted with increasing somnolence and respiratory distress. Arterial blood gas results are pH 7.27, PaCO# 68 mmHg, and PaO# 58 mmHg. BiPAP is initiated. Which condition is MOST appropriate for the CDI specialist to consider as a clarification opportunity?
Antwort: C
Begründung:
The findings strongly support a clarification opportunity for acute hypercapnic respiratory failure. The patient has a substantial acute rise in PaCO# above the documented baseline, respiratory acidemia with a pH of 7.27, hypoxemia, altered mental status, respiratory distress, and escalation to noninvasive ventilatory support.
In chronic CO# retention, renal compensation commonly increases serum bicarbonate and may allow a relatively preserved pH. A pronounced fall in pH in conjunction with a significant increase in PaCO# suggests an acute ventilatory deterioration. The need for BiPAP provides additional evidence of clinically significant respiratory compromise.
Option C is incorrect because the acidemia is driven primarily by elevated carbon dioxide, indicating respiratory rather than metabolic acidosis. Option A fails to capture the apparent acute deterioration from the patient's baseline. Option D is inconsistent with the physiologic abnormalities and treatment intensity.
The CDI specialist must still obtain provider documentation rather than independently diagnose respiratory failure. The CCDS examination specifically includes acute/chronic respiratory failure, COPD, ventilation support, and diagnostic-test interpretation among expected clinical competencies.
CCDS Reference Topics: Acute respiratory failure; hypercapnia; ABG interpretation; COPD; noninvasive ventilation.
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99. Frage
A patient with active breast cancer is admitted solely to receive a scheduled cycle of antineoplastic chemotherapy. No complication or acute disease process is responsible for the admission. Which diagnosis is generally sequenced first?
Antwort: A
Begründung:
When an inpatient encounter is solely for administration of chemotherapy, the encounter-for-chemotherapy code is generally sequenced first, followed by the code identifying the malignancy being treated.
This represents an important exception to the usual expectation that the underlying disease is the principal diagnosis. The circumstances of admission are specifically treatment administration rather than management of an acute complication of the malignancy.
If, however, the patient were admitted because of a complication-such as chemotherapy-induced neutropenic fever, dehydration, anemia, or another adverse effect-the principal-diagnosis analysis would follow the applicable guideline for that condition rather than automatically using the chemotherapy encounter code.
Similarly, if chemotherapy were administered incidentally during a hospitalization principally required for another condition, the encounter-for-chemotherapy code would not displace the actual principal diagnosis.
CDI professionals should therefore distinguish planned treatment encounters from admissions caused by complications of treatment or malignancy.
Clear documentation regarding the reason for admission, cancer site, treatment intent, metastatic disease, and complications helps support proper sequencing and accurate oncology data.
CCDS Reference Topics: Antineoplastic chemotherapy; encounter codes; neoplasm sequencing; principal diagnosis; oncology documentation.
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100. Frage
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?
Antwort: D
Begründung:
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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101. Frage
A neurologist documents acute cerebral infarction. A qualified stroke nurse records the NIH Stroke Scale score in the medical record. Which statement is MOST accurate?
Antwort: C
Begründung:
ICD-10-CM permits the NIH Stroke Scale score to be reported from documentation by an appropriate clinician other than the provider responsible for establishing the diagnosis. The underlying stroke diagnosis itself must be appropriately documented by the provider.
This is similar to other specified exceptions such as BMI, pressure-ulcer stage, coma scale values, and certain additional clinical elements for which qualified non-provider documentation may support code assignment.
The exception does not mean that a stroke nurse can independently establish cerebral infarction for coding.
Rather, once the provider has documented the stroke, the nurse's formal NIHSS assessment can supply the standardized severity measurement.
This approach recognizes that specially trained clinical professionals routinely collect and document these structured measurements as part of patient care.
If multiple NIHSS values are documented, the applicable coding instructions and timing requirements should be followed rather than simply selecting the highest score because it produces a different code.
For CDI professionals, awareness of these non-provider documentation exceptions prevents unnecessary physician queries while ensuring that important severity information is not lost.
CCDS Reference Topics: NIH Stroke Scale; cerebral infarction; non-provider documentation; coding exceptions; stroke severity.
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102. Frage
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