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| Section | Weight | Objectives |
|---|---|---|
| Impact of reportable diagnoses on quality of care | 8.33% | - Hospital-Acquired Condition Reduction Program - Coded data elements affecting Patient Safety Indicators - Hospital Inpatient Quality Reporting Program - CDI impact on Hospital Value-Based Purchasing - Hospital Value-Based Purchasing - Mortality reviews and observed/expected ratios - Patient Safety Indicators - Documentation and code assignment impact on mortality index - Hospital Readmissions Reduction Program - 30-day mortality measures - Quality data from record abstraction and claims data - Healthcare-associated infections and complication codes |
| Healthcare regulations, reimbursement, and documentation requirements related to the IPPS | 12.5% | - Documentation impact on IPPS reimbursement - Inpatient admission criteria and CMS Two-Midnight Rule - Principal diagnosis and medical necessity - Medicare Severity Diagnosis Related Groups (MS-DRGs) - Coding and billing practices vulnerable to denial - Complication/comorbidity (CC) - Case mix index (CMI) - Medicare contractors and their impact on CDI - Major complication/comorbidity (MCC) - Medical staff and clinical staff documentation responsibilities - Documentation and medical necessity of setting - IPPS and its updates and revisions |
| Communication skills | 9.17% | - Effective and non-confrontational physician communication - Roles and responsibilities of CDI specialists - Educational presentations for healthcare departments and administration - Verbal versus written physician communication - Roles and responsibilities of coders working with CDI departments - Physician education forms and tools - Reconciling CDI working DRGs with final coded DRGs |
| Healthcare facility CDI program analysis | 8.33% | - CDI specialist productivity metrics - Severity of illness and risk of mortality - Basic computer and software application skills - Provider response rates - Tracking and trending physician, department, and hospital performance - Patient Safety Indicators - Case mix index (CMI) - Publicly reported data - CC/MCC capture - Physician performance measurement - PEPPER data - CDI program forecasting - Hospital-specific financial data - Hospital Value-Based Purchasing measures - High-frequency DRGs |
| Medical record documentation | 19.17% | - Health record elements used for diagnosis and procedure code assignment - Physician query formats - Addressing diagnoses without clinical support - Provider role and diagnosis code assignment - When a physician query is warranted - Situations in which queries are not appropriate - Documentation requiring clarification - Translating clinical indicators into compliant queries - Compliant and noncompliant queries - Types of physician queries - Clinical indicators - ACDIS/AHIMA Guidelines for Achieving a Compliant Query Practice |
| Official Guidelines for Coding and Reporting | 14.17% | - Hospital-acquired conditions - Secondary diagnosis assignment - Discharge dispositions and transfers - Principal diagnosis assignment - Working DRG assignment for multiple diagnoses - Coding guidelines for principal diagnosis selection - Official Guidelines for Coding and Reporting updates - AHA Coding Clinic - Present on admission indicators |
| Professionalism, ethics, and compliance | 9.17% | - Compliance risks indicated by PEPPER - Potential DRG creep - Medical record confidentiality - Leading queries - DRG compliance initiatives - CDI department goals beyond reimbursement |
| Anatomy and physiology, pathophysiology, pharmacology, and medical terminology | 19.17% | - Myeloproliferative diseases and disorders and poorly differentiated neoplasms - Diseases and disorders of the kidney and urinary tract - Clinical indicators and query opportunities by Major Diagnostic Category - Injuries, poisonings, and toxic effects of drugs - HIV infections - Diseases and disorders of the musculoskeletal system - Diseases and disorders of the digestive system - Diseases and disorders of the nervous system - Endocrine, nutritional, and metabolic diseases and disorders - Diseases and disorders of the respiratory system - Alcohol/drug use and alcohol/drug-induced organic brain disorders - Diseases and disorders of the skin, subcutaneous tissue, and breast - Diseases and disorders of the hepatobiliary system - Diseases and disorders of the blood and blood-forming organs and immunological disorders - Mental diseases and disorders - Pharmaceuticals and disease processes - Medications as clinical indicators - Infectious and parasitic diseases - Diseases and disorders of the circulatory system - Diagnostic tests as clinical indicators - Standard medical abbreviations |
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NEW QUESTION # 143
A CDI program is developing a query escalation policy. A clinically significant query remains unanswered despite normal reminders. Which action is MOST appropriate?
Answer: D
Explanation:
An unanswered clinically significant query should be managed through the organization's defined escalation process. The process may involve CDI leadership, coding leadership, a physician advisor, department leadership, or other designated personnel, depending on organizational policy.
Neither CDI nor coding may independently supply the missing diagnosis because diagnostic conclusions remain the provider's responsibility. Removing an unresolved query simply to accelerate billing can undermine documentation integrity and may create compliance problems.
Escalation policies should be standardized rather than applied only when a particular diagnosis affects reimbursement. Policies commonly address expected response time, reminder intervals, responsible escalation personnel, high-priority queries, retrospective queries, and final-bill procedures.
The 2026 ACDIS/AHIMA Guidelines for Achieving a Compliant Query Practice supersede prior versions and serve as the current foundational guidance for organizations establishing compliant query policies and procedures.
A mature escalation process balances timely claim completion with respect for provider workload and independent clinical judgment. Its purpose is obtaining complete and accurate documentation, not forcing agreement with a CDI-generated diagnosis.
CCDS Reference Topics: Query escalation; organizational policy; unanswered queries; compliance; provider responsibility.
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NEW QUESTION # 144
A CDI manager notes that the physician query response rate is 98%, but only 55% of queries are answered before discharge. Which metric should receive the MOST immediate workflow analysis?
Answer: D
Explanation:
The overall response rate is excellent at 98%, but the fact that only 55% of queries are resolved before discharge indicates a meaningful concurrent-workflow issue.
Concurrent CDI is most effective when clarification occurs while the patient remains hospitalized and the physician has immediate access to the clinical context. Delayed responses can contribute to retrospective work, final-bill holds, coding delays, and administrative escalation.
The CDI manager should determine whether delays cluster by provider, specialty, query type, unit, day of week, discharge timing, or electronic-query process. Other factors may include insufficient notification, physician workflow, poor escalation protocols, or queries being issued too late in the stay.
CMI and MCC volume do not directly measure response timeliness and should not substitute for analysis of the actual operational problem.
Importantly, programs should not pressure physicians into rapid but clinically superficial responses. Query timing initiatives must preserve thoughtful provider judgment and compliant communication.
ACDIS identifies medical-record review, communication, query technique, and data-mining/reporting functions among core CCDS competencies.
CCDS Reference Topics: Query timeliness; concurrent CDI; physician engagement; workflow analysis; program metrics.
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NEW QUESTION # 145
CMS identifies the complete logic used to assign inpatient cases to MS-DRGs in which FY 2026 resource?
Answer: C
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 # 146
A 34-year-old female was admitted from a group home with uncontrolled diabetes. A CDI specialist must query to specify the patient's mental incapacity since it makes management of the diabetes more difficult.
Which of the following terminology recognized by ICD-10-CM could result in the assignment of a comorbid condition?
Answer: B
Explanation:
Severe intellectual disability is recognized ICD-10-CM terminology and maps to F72, Severe intellectual disabilities. The other phrases are not equivalent standardized ICD-10-CM diagnostic terminology.
This distinction is highly relevant to CDI. Terms used conversationally in the clinical record do not necessarily provide sufficient specificity or map cleanly to reportable ICD-10-CM diagnoses. When a patient's cognitive or developmental condition affects treatment, monitoring, self-management, nursing requirements, or the complexity of care, the CDI specialist should seek clinically appropriate provider documentation using recognized diagnostic terminology.
For FY 2026 MS-DRG logic, CMS identifies F72 as a CC, meaning it can qualify as a complication
/comorbidity when it meets secondary-diagnosis reporting requirements. That does not mean the CDI specialist should query merely for reimbursement impact. The query must be clinically justified by the record and should allow the provider to determine the correct diagnosis.
"Severe mental challenge," "acute mental incapacity," and "acute intellectual disability" do not represent the same codable disease classification.
CCDS Reference Topics: Medical terminology; mental/behavioral and neurodevelopmental disorders; CC recognition; clinically supported query opportunities.
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NEW QUESTION # 147
During a quarter, a CDI department issued 800 provider queries. Providers answered 720 queries, and 540 of those responses agreed with the clarification proposed by the clinical evidence. What was the provider query response rate?
Answer: C
Explanation:
The provider query response rate is calculated by dividing answered queries by total queries issued:
720 ÷ 800 × 100 = 90%.
Therefore, the correct answer is 90%.
The 540 responses agreeing with the clarification are relevant to a different measure: provider agreement rate.
If agreement were calculated against answered queries, it would be 540 ÷ 720 = 75%.
These metrics should not be confused. Response rate measures whether providers participate in the clarification process, whereas agreement rate measures the proportion of responses that substantively agree with the diagnosis or clarification being evaluated.
A lower agreement rate is not necessarily evidence of poor CDI performance. Providers should remain free to disagree, document another supported diagnosis, rule out a condition, or indicate that the issue cannot be determined.
A CDI manager should trend response rate, agreement rate, response time, unanswered-query aging, retrospective-query percentage, and query type together rather than judging program success from a single number.
The 2026 ACDIS/AHIMA guidance reinforces provider independence as a fundamental aspect of a compliant query process.
CCDS Reference Topics: Query response rate; agreement rate; CDI metrics; provider engagement; program analysis.
NEW QUESTION # 148
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