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| Section | Weight | Objectives |
|---|---|---|
| Healthcare regulations, reimbursement, and documentation requirements related to the IPPS | 12.5% | - Inpatient admission criteria and CMS Two-Midnight Rule - Complication/comorbidity (CC) - Case mix index (CMI) - Medical staff and clinical staff documentation responsibilities - Principal diagnosis and medical necessity - Major complication/comorbidity (MCC) - Coding and billing practices vulnerable to denial - Documentation and medical necessity of setting - Medicare Severity Diagnosis Related Groups (MS-DRGs) - IPPS and its updates and revisions - Documentation impact on IPPS reimbursement - Medicare contractors and their impact on CDI |
| Communication skills | 9.17% | - Educational presentations for healthcare departments and administration - Roles and responsibilities of CDI specialists - Verbal versus written physician communication - Effective and non-confrontational physician communication - Reconciling CDI working DRGs with final coded DRGs - Roles and responsibilities of coders working with CDI departments - Physician education forms and tools |
| Anatomy and physiology, pathophysiology, pharmacology, and medical terminology | 19.17% | - Alcohol/drug use and alcohol/drug-induced organic brain disorders - 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 - Diseases and disorders of the hepatobiliary system - Diseases and disorders of the circulatory system - Clinical indicators and query opportunities by Major Diagnostic Category - Endocrine, nutritional, and metabolic diseases and disorders - HIV infections - Mental diseases and disorders - Diseases and disorders of the nervous system - Infectious and parasitic diseases - Diseases and disorders of the kidney and urinary tract - Pharmaceuticals and disease processes - Medications as clinical indicators - Diseases and disorders of the skin, subcutaneous tissue, and breast - Diseases and disorders of the digestive system - Diseases and disorders of the musculoskeletal system - Myeloproliferative diseases and disorders and poorly differentiated neoplasms - Diseases and disorders of the respiratory system - Standard medical abbreviations |
| Official Guidelines for Coding and Reporting | 14.17% | - AHA Coding Clinic - Principal diagnosis assignment - Present on admission indicators - Discharge dispositions and transfers - Coding guidelines for principal diagnosis selection - Official Guidelines for Coding and Reporting updates - Secondary diagnosis assignment - Hospital-acquired conditions - Working DRG assignment for multiple diagnoses |
| Professionalism, ethics, and compliance | 9.17% | - Compliance risks indicated by PEPPER - Potential DRG creep - Medical record confidentiality - CDI department goals beyond reimbursement - DRG compliance initiatives - Leading queries |
| Medical record documentation | 19.17% | - Addressing diagnoses without clinical support - Types of physician queries - Clinical indicators - When a physician query is warranted - Translating clinical indicators into compliant queries - Provider role and diagnosis code assignment - Situations in which queries are not appropriate - Compliant and noncompliant queries - Physician query formats - Health record elements used for diagnosis and procedure code assignment - Documentation requiring clarification - ACDIS/AHIMA Guidelines for Achieving a Compliant Query Practice |
| Impact of reportable diagnoses on quality of care | 8.33% | - Mortality reviews and observed/expected ratios - Patient Safety Indicators - Quality data from record abstraction and claims data - CDI impact on Hospital Value-Based Purchasing - Healthcare-associated infections and complication codes - Hospital Readmissions Reduction Program - Hospital Inpatient Quality Reporting Program - Coded data elements affecting Patient Safety Indicators - Hospital-Acquired Condition Reduction Program - Hospital Value-Based Purchasing - Documentation and code assignment impact on mortality index - 30-day mortality measures |
| Healthcare facility CDI program analysis | 8.33% | - Severity of illness and risk of mortality - Case mix index (CMI) - Patient Safety Indicators - CDI specialist productivity metrics - PEPPER data - Publicly reported data - Hospital-specific financial data - CDI program forecasting - Hospital Value-Based Purchasing measures - Provider response rates - Tracking and trending physician, department, and hospital performance - Basic computer and software application skills - CC/MCC capture - High-frequency DRGs - Physician performance measurement |
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NEW QUESTION # 143
A patient with severe cachexia and substantial loss of appetite requires pharmacologic treatment to stimulate appetite. Which of the following medications is most commonly associated with this indication?
Answer: B
Explanation:
Megestrol acetate is the correct choice. This item is adapted from an official ACDIS CCDS sample question in the Candidate Handbook, where Megace-megestrol acetate-is identified as the appropriate appetite- stimulating medication.
Megestrol acetate is a synthetic progestational agent with recognized appetite-stimulating effects. Current U.
S. prescribing information specifically identifies megestrol acetate oral suspension for anorexia, cachexia, or significant unexplained weight loss in patients with AIDS. Its use illustrates why CDI specialists need functional knowledge of pharmacology: medication profiles can provide clinically relevant clues to diagnoses under evaluation, although a medication alone never establishes a reportable diagnosis.
Memantine is primarily used in Alzheimer's disease and is not an appetite stimulant. Levothyroxine replaces thyroid hormone in hypothyroidism. Sibutramine was historically used for weight reduction rather than cachexia and is therefore directionally opposite to the desired effect.
In CDI review, identification of megestrol may prompt assessment of the record for malnutrition, cachexia, malignancy-related weight loss, HIV-associated wasting, or another underlying cause, but the provider must document the diagnosis.
CCDS Reference Topics: Pharmacology; cachexia; nutrition disorders; clinical indicators.
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NEW QUESTION # 144
When a physician documents the abbreviation "HCAP" in the health record, the BEST action for a CDI specialist to take is to:
Answer: C
Explanation:
The CDI specialist should seek greater specificity regarding the pneumonia. The abbreviation HCAP historically referred to "healthcare-associated pneumonia," but that terminology does not identify a causative organism or a sufficiently specific ICD-10-CM pneumonia diagnosis.
From a CDI perspective, the clinically relevant clarification may involve whether the pneumonia is bacterial, viral, aspiration-related, gram-negative, due to a specific organism, or otherwise characterized by the provider based on the available evidence. Culture results, aspiration risk, recent healthcare exposure, antibiotic selection, radiology, respiratory cultures, and infectious-disease documentation may provide appropriate clinical indicators for a neutral query.
Simply assigning a generic pneumonia working code fails to resolve the documentation deficiency. Asking only whether HCAP means "healthcare-acquired pneumonia" merely expands the abbreviation without producing useful etiologic specificity. "Complex pneumonia" is not an appropriate substitute diagnostic classification.
The CDI specialist must also avoid assuming that recent healthcare exposure establishes resistant-organism pneumonia. Contemporary clinical practice has moved away from treating HCAP as a standalone etiologic category because exposure alone does not reliably establish a particular pathogen.
CCDS Reference Topics: Pneumonia specificity; abbreviations; diagnostic clarification; compliant provider queries.
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NEW QUESTION # 145
The PRIMARY goal of a CDI specialist's work is to support complete and specific documentation that results in:
Answer: B
Explanation:
The fundamental objective of clinical documentation integrity is to ensure that the health record accurately represents the patient's clinical condition, including severity of illness, complexity, acuity, diagnoses, treatments, and outcomes. Reimbursement is an important downstream consequence of documentation and coding, but maximizing reimbursement is not the primary professional objective of CDI.
The ACDIS CCDS framework describes the CDI specialist as applying clinical knowledge to determine how documentation translates into coded data and educating providers so the record appropriately reflects severity, complexity, and acuity. This distinction is critical from an ethics and compliance perspective. A CDI program must pursue documentation accuracy whether clarification raises, lowers, or leaves reimbursement unchanged.
Reducing HACs is principally a clinical-quality and patient-safety function. CDI can improve the accuracy with which HACs are identified and reported, but it does not directly prevent those conditions. Similarly, improved provider communication is an important mechanism used by CDI professionals, but it is a means toward accurate documentation rather than the primary endpoint.
Therefore, A most accurately captures the broad clinical, coding, quality, and compliance purpose of CDI.
CCDS Reference Topics: Professionalism, ethics, and compliance; Medical record documentation; goals of CDI beyond reimbursement.
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NEW QUESTION # 146
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 # 147
A patient has a history of a type 2 MI 30 days ago. The patient is admitted for chest pain which is determined to be an NSTEMI. Which of the following diagnosis(es) should be coded to identify the working MS-DRG?
Answer: D
Explanation:
The current NSTEMI is the acute condition driving the admission. The prior type 2 myocardial infarction occurred 30 days earlier, placing it beyond the ICD-10-CM four-week acute-MI reporting window. The Official Guidelines state that category I21 codes may continue to be reported while an MI is four weeks old or less; after that period, an aftercare code may be appropriate when continued MI-related care is being provided, or I25.2 may describe an old/healed MI when applicable.
There is an additional reason not to select a "subsequent MI" answer. Category I22 is restricted to qualifying subsequent type 1 or unspecified acute myocardial infarctions occurring within four weeks of the initial qualifying MI. Type 2 MI is classified to I21.A1 rather than I22.
Therefore, the previous type 2 MI does not support selection of a subsequent-MI option in this 30-day scenario. The active NSTEMI is the diagnosis relevant to the working MS-DRG. "Initial encounter" in answer B is exam terminology rather than an ICD-10-CM seventh-character designation for MI, but B is clearly the intended correct choice.
CCDS Reference Topics: Official Guidelines-acute myocardial infarction; working MS-DRG; circulatory disorders.
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NEW QUESTION # 148
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