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| Section | Weight | Objectives |
|---|---|---|
| Impact of reportable diagnoses on quality of care | 8.33% | - Coded data elements affecting Patient Safety Indicators - Hospital Readmissions Reduction Program - Hospital Inpatient Quality Reporting Program - Quality data from record abstraction and claims data - CDI impact on Hospital Value-Based Purchasing - 30-day mortality measures - Documentation and code assignment impact on mortality index - Mortality reviews and observed/expected ratios - Hospital-Acquired Condition Reduction Program - Patient Safety Indicators - Healthcare-associated infections and complication codes - Hospital Value-Based Purchasing |
| Professionalism, ethics, and compliance | 9.17% | - DRG compliance initiatives - CDI department goals beyond reimbursement - Potential DRG creep - Medical record confidentiality - Leading queries - Compliance risks indicated by PEPPER |
| Healthcare regulations, reimbursement, and documentation requirements related to the IPPS | 12.5% | - Inpatient admission criteria and CMS Two-Midnight Rule - Documentation impact on IPPS reimbursement - Documentation and medical necessity of setting - Major complication/comorbidity (MCC) - Medicare Severity Diagnosis Related Groups (MS-DRGs) - Coding and billing practices vulnerable to denial - Medical staff and clinical staff documentation responsibilities - Case mix index (CMI) - IPPS and its updates and revisions - Medicare contractors and their impact on CDI - Principal diagnosis and medical necessity - Complication/comorbidity (CC) |
| Official Guidelines for Coding and Reporting | 14.17% | - Working DRG assignment for multiple diagnoses - Principal diagnosis assignment - Discharge dispositions and transfers - Official Guidelines for Coding and Reporting updates - AHA Coding Clinic - Present on admission indicators - Coding guidelines for principal diagnosis selection - Hospital-acquired conditions - Secondary diagnosis assignment |
| Healthcare facility CDI program analysis | 8.33% | - High-frequency DRGs - Provider response rates - CC/MCC capture - PEPPER data - Basic computer and software application skills - Case mix index (CMI) - Tracking and trending physician, department, and hospital performance - CDI program forecasting - Hospital-specific financial data - Publicly reported data - CDI specialist productivity metrics - Patient Safety Indicators - Severity of illness and risk of mortality - Hospital Value-Based Purchasing measures - Physician performance measurement |
| Medical record documentation | 19.17% | - Translating clinical indicators into compliant queries - Compliant and noncompliant queries - Provider role and diagnosis code assignment - Types of physician queries - Situations in which queries are not appropriate - Physician query formats - Clinical indicators - Addressing diagnoses without clinical support - ACDIS/AHIMA Guidelines for Achieving a Compliant Query Practice - When a physician query is warranted - Documentation requiring clarification - Health record elements used for diagnosis and procedure code assignment |
| Communication skills | 9.17% | - Physician education forms and tools - Roles and responsibilities of coders working with CDI departments - Verbal versus written physician communication - Roles and responsibilities of CDI specialists - Effective and non-confrontational physician communication - Educational presentations for healthcare departments and administration - Reconciling CDI working DRGs with final coded DRGs |
| Anatomy and physiology, pathophysiology, pharmacology, and medical terminology | 19.17% | - Diseases and disorders of the hepatobiliary system - Alcohol/drug use and alcohol/drug-induced organic brain disorders - Diseases and disorders of the skin, subcutaneous tissue, and breast - Pharmaceuticals and disease processes - Mental diseases and disorders - Diseases and disorders of the respiratory system - Injuries, poisonings, and toxic effects of drugs - Clinical indicators and query opportunities by Major Diagnostic Category - HIV infections - Diseases and disorders of the digestive system - Endocrine, nutritional, and metabolic diseases and disorders - Myeloproliferative diseases and disorders and poorly differentiated neoplasms - Infectious and parasitic diseases - Diseases and disorders of the blood and blood-forming organs and immunological disorders - Medications as clinical indicators - Diagnostic tests as clinical indicators - Diseases and disorders of the circulatory system - Diseases and disorders of the musculoskeletal system - Diseases and disorders of the kidney and urinary tract - Standard medical abbreviations - Diseases and disorders of the nervous system |
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NEW QUESTION # 108
A patient with chronic heart failure presents with confusion, nausea, and seizures. Serum sodium is 116 mEq
/L. The patient is treated with hypertonic saline and intensive electrolyte monitoring. Which diagnosis is MOST strongly supported for clarification?
Answer: D
Explanation:
The findings strongly support severe symptomatic hyponatremia. A serum sodium of 116 mEq/L represents marked reduction in extracellular sodium concentration, and the neurologic manifestations-confusion and seizures-indicate clinically significant cerebral effects.
Severe hyponatremia can produce cerebral edema because reduced extracellular osmolality promotes water movement into brain cells. Symptoms can range from nausea and headache to confusion, seizures, coma, and respiratory arrest in extreme cases.
Administration of hypertonic saline further demonstrates that clinicians are treating a significant sodium disturbance rather than an incidental laboratory abnormality. The rate of sodium correction requires careful monitoring because overly rapid correction, particularly in chronic hyponatremia, can cause osmotic demyelination.
Heart failure can contribute through impaired free-water excretion and neurohormonal activation, but CDI should not independently assign the etiology unless the provider documents it.
The specialist should present the sodium level, symptoms, treatment, and clinical course and request clarification if no corresponding diagnosis exists.
Hypernatremia represents elevated rather than decreased sodium. Hypercalcemia and respiratory alkalosis do not explain the sodium abnormality.
CCDS Reference Topics: Hyponatremia; electrolyte physiology; neurologic manifestations; clinical indicators; documentation specificity.
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NEW QUESTION # 109
Which pressure-ulcer category is specifically included in the traditional CMS HAC payment policy when the condition is not present on admission?
Answer: D
Explanation:
CMS's Hospital-Acquired Condition payment framework specifically identifies Stage III and Stage IV pressure ulcers among the defined HAC categories when applicable conditions are not present on admission.
The distinction is important because not every pressure injury automatically triggers HAC payment treatment.
Stage and POA status therefore require accurate documentation.
A hospital-acquired pressure ulcer remains reportable even when HAC payment provisions apply. CMS does not instruct hospitals to suppress or omit such conditions. Instead, defined HAC diagnoses that are not POA may lose the CC/MCC payment effect they otherwise would contribute to the MS-DRG, subject to applicable grouper rules.
The CDI specialist should ensure that wound location, laterality when relevant, stage, progression, and timing are accurately documented. Qualified wound-care nurse documentation may be used for pressure-ulcer staging under the ICD-10-CM non-provider documentation exception, while the diagnosis itself remains subject to provider-documentation requirements.
CDI professionals must also distinguish the HAC/POA MS-DRG payment provision from the separate HAC Reduction Program, which reduces applicable hospital payments by 1% for hospitals in the worst-performing quartile.
CCDS Reference Topics: HACs; pressure ulcers; POA; MS-DRG adjustment; wound documentation.
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NEW QUESTION # 110
Which CMS program can reduce an eligible hospital's Medicare base operating DRG payments by as much as
3% because of excess readmissions?
Answer: A
Explanation:
The Hospital Readmissions Reduction Program (HRRP) reduces payments to applicable hospitals with excess readmissions for specified conditions and procedures. CMS calculates a payment adjustment factor ranging from 1.0 to 0.97, meaning the maximum reduction is 3%.
The adjustment applies to applicable Medicare fee-for-service base operating DRG payments rather than solely to the readmission cases themselves.
This differs from the HAC Reduction Program, which applies a 1% reduction to hospitals in the worst- performing quartile based on defined hospital-acquired-condition measures. Hospital Value-Based Purchasing uses another methodology in which 2% of participating hospitals' base operating DRG payments funds value- based incentive payments.
For CDI professionals, readmission programs demonstrate how clinical documentation can influence more than individual MS-DRG reimbursement. Accurate documentation of comorbidities, principal diagnoses, complications, discharge circumstances, and disease severity contributes to reliable risk-adjusted data.
However, CDI intervention must remain focused on clinical accuracy rather than attempting to alter readmission metrics through unsupported diagnoses.
CCDS Reference Topics: HRRP; readmissions; quality reimbursement; IPPS; risk adjustment.
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NEW QUESTION # 111
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 # 112
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: B
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 # 113
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