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| Section | Weight | Objectives |
|---|---|---|
| Topic 1: Professionalism, ethics, and compliance | 9.17% | - Medical record confidentiality - CDI department goals beyond reimbursement - DRG compliance initiatives - Compliance risks indicated by PEPPER - Potential DRG creep - Leading queries |
| Topic 2: Impact of reportable diagnoses on quality of care | 8.33% | - CDI impact on Hospital Value-Based Purchasing - Hospital Readmissions Reduction Program - 30-day mortality measures - Coded data elements affecting Patient Safety Indicators - Patient Safety Indicators - Hospital Inpatient Quality Reporting Program - Healthcare-associated infections and complication codes - Documentation and code assignment impact on mortality index - Hospital-Acquired Condition Reduction Program - Mortality reviews and observed/expected ratios - Hospital Value-Based Purchasing - Quality data from record abstraction and claims data |
| Topic 3: Healthcare facility CDI program analysis | 8.33% | - PEPPER data - Tracking and trending physician, department, and hospital performance - Hospital Value-Based Purchasing measures - Physician performance measurement - Patient Safety Indicators - Hospital-specific financial data - Basic computer and software application skills - Provider response rates - CC/MCC capture - CDI specialist productivity metrics - CDI program forecasting - High-frequency DRGs - Publicly reported data - Severity of illness and risk of mortality - Case mix index (CMI) |
| Topic 4: Anatomy and physiology, pathophysiology, pharmacology, and medical terminology | 19.17% | - Diseases and disorders of the musculoskeletal system - Myeloproliferative diseases and disorders and poorly differentiated neoplasms - Clinical indicators and query opportunities by Major Diagnostic Category - Diseases and disorders of the nervous system - Injuries, poisonings, and toxic effects of drugs - Diseases and disorders of the circulatory system - Endocrine, nutritional, and metabolic diseases and disorders - Mental diseases and disorders - Diagnostic tests as clinical indicators - Pharmaceuticals and disease processes - Medications as clinical indicators - Infectious and parasitic diseases - Diseases and disorders of the digestive system - Diseases and disorders of the kidney and urinary tract - Diseases and disorders of the blood and blood-forming organs and immunological disorders - Diseases and disorders of the respiratory system - HIV infections - Alcohol/drug use and alcohol/drug-induced organic brain disorders - Diseases and disorders of the skin, subcutaneous tissue, and breast - Standard medical abbreviations - Diseases and disorders of the hepatobiliary system |
| Topic 5: Healthcare regulations, reimbursement, and documentation requirements related to the IPPS | 12.5% | - Documentation impact on IPPS reimbursement - IPPS and its updates and revisions - Principal diagnosis and medical necessity - Coding and billing practices vulnerable to denial - Complication/comorbidity (CC) - Medical staff and clinical staff documentation responsibilities - Major complication/comorbidity (MCC) - Documentation and medical necessity of setting - Inpatient admission criteria and CMS Two-Midnight Rule - Case mix index (CMI) - Medicare Severity Diagnosis Related Groups (MS-DRGs) - Medicare contractors and their impact on CDI |
| Topic 6: Communication skills | 9.17% | - Reconciling CDI working DRGs with final coded DRGs - Verbal versus written physician communication - Physician education forms and tools - Roles and responsibilities of coders working with CDI departments - Effective and non-confrontational physician communication - Roles and responsibilities of CDI specialists - Educational presentations for healthcare departments and administration |
| Topic 7: Medical record documentation | 19.17% | - Translating clinical indicators into compliant queries - Physician query formats - ACDIS/AHIMA Guidelines for Achieving a Compliant Query Practice - Provider role and diagnosis code assignment - When a physician query is warranted - Compliant and noncompliant queries - Documentation requiring clarification - Health record elements used for diagnosis and procedure code assignment - Addressing diagnoses without clinical support - Situations in which queries are not appropriate - Clinical indicators - Types of physician queries |
| Topic 8: Official Guidelines for Coding and Reporting | 14.17% | - Official Guidelines for Coding and Reporting updates - Principal diagnosis assignment - Discharge dispositions and transfers - Coding guidelines for principal diagnosis selection - Present on admission indicators - Hospital-acquired conditions - Working DRG assignment for multiple diagnoses - AHA Coding Clinic - Secondary diagnosis assignment |
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NEW QUESTION # 43
A hospital has a total MS-DRG relative weight of 2,640 for 1,600 inpatient discharges. What is its case mix index?
Answer: A
Explanation:
Case mix index is calculated by dividing the sum of MS-DRG relative weights by the number of inpatient discharges:
2,640 ÷ 1,600 = 1.65
Therefore, the CMI is 1.65.
CMI represents the average relative resource intensity of the hospital's inpatient cases. It is affected by the types of patients treated, surgical versus medical mix, tertiary services, transplant or trauma volume, documentation specificity, coding accuracy, and annual changes to MS-DRG relative weights and grouper logic.
CMS publishes hospital case-mix information and FY 2026 relative weighting factors through the IPPS Final Rule supporting data. Table 5 contains MS-DRGs and relative weighting factors, while Table 2 contains hospital-specific case-mix information.
A decline in CMI should not automatically be interpreted as a CDI failure. A shift toward lower-complexity cases or changes in service lines can legitimately reduce CMI even with excellent documentation.
CDI managers should therefore trend CMI alongside diagnosis capture, surgical volume, service lines, payer population, coding reconciliation, and quality indicators.
CCDS Reference Topics: Case mix index; MS-DRG relative weight; CDI analytics; hospital performance.
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NEW QUESTION # 44
When a physician documents the abbreviation "HCAP" in the health record, the BEST action for a CDI specialist to take is to:
Answer: D
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 # 45
Hospital A is developing a query policy. Open-ended queries will be encouraged. The provider is expected to document on the query form, which will be retained as part of the health record. Hospital A will remove any unanswered queries and shred them to avoid any incomplete forms within the health record. Which of the following is considered a high-risk query practice?
Answer: C
Explanation:
The high-risk practice is destroying unanswered queries. Query retention should be governed by an established organizational policy and should not depend on whether the provider answers the query.
Selectively destroying unanswered queries can create significant compliance, audit, and record-integrity concerns because it removes evidence of the documentation-clarification process.
ACDIS/AHIMA guidance has consistently required organizations to establish query-retention policies.
Queries may be retained as part of the permanent health record or maintained as a retrievable business record according to organizational policy and legal requirements. The current 2026 ACDIS/AHIMA query practice guidance supersedes all previous editions, reinforcing the importance of a standardized, defensible query process.
Keeping queries in the health record is not inherently problematic when policy defines them as part of that record. Likewise, a new diagnosis may be included in a multiple-choice query when it is supported by patient- specific clinical indicators and the choices remain nonleading. A yes/no query can also be compliant in defined circumstances, such as clarification of a diagnosis or relationship already documented.
Selective destruction is therefore the clear compliance risk.
CCDS Reference Topics: Query retention; compliance; organizational query policy; audit integrity.
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NEW QUESTION # 46
A patient is admitted with a stage 2 sacral pressure ulcer. During the hospitalization, the ulcer progresses and is documented as stage 3 at the same site. How should the pressure ulcer be reported?
Answer: B
Explanation:
The FY 2026 ICD-10-CM Official Guidelines specifically address a pressure ulcer that progresses to a higher stage during an inpatient admission. Two codes are assigned: one representing the site and stage present on admission and another representing the same ulcer site at the highest stage documented during the hospitalization.
Therefore, this patient's stage 2 sacral pressure ulcer on admission and subsequent progression to stage 3 must both be represented according to the applicable coding instructions.
The distinction is important for both clinical and quality purposes because the record must accurately show what condition existed when the patient entered the hospital and how the wound subsequently evolved.
Coding only the stage 3 ulcer would lose information about its status at admission. Coding only stage 2 would fail to represent the deterioration that occurred during the stay.
Pressure-ulcer staging is also one of the circumstances in which qualified non-provider clinician documentation, such as wound-care nursing documentation, may be used to establish stage when the diagnosis itself is appropriately documented.
For CDI, accurate wound location, stage, progression, and POA documentation are essential because advanced pressure injuries may influence MS-DRG severity and hospital quality reporting.
CCDS Reference Topics: Pressure ulcers; staging; POA; wound-care documentation; Official Guidelines.
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NEW QUESTION # 47
Under the FY 2026 Hospital-Acquired Condition Reduction Program, which hospitals are subject to the program's payment reduction?
Answer: A
Explanation:
Under the FY 2026 Hospital-Acquired Condition Reduction Program (HACRP), applicable subsection (d) hospitals in the worst-performing quartile based on the Total HAC Score receive a 1% payment reduction on applicable Medicare fee-for-service payments. CMS defines the worst-performing quartile as hospitals whose Total HAC Score is above the 75th percentile.
The FY 2026 program incorporates the CMS Patient Safety and Adverse Events Composite (PSI 90) plus five healthcare-associated infection measures: CLABSI, CAUTI, specified surgical-site infection, MRSA bacteremia, and C. difficile infection.
A single HAC does not automatically trigger the hospital-wide 1% HACRP reduction. Likewise, CMI is not the criterion used to determine HACRP penalties.
It is also important for CCDS candidates to distinguish the HAC Reduction Program from the separate DRA HAC/POA payment provision. CMS explicitly identifies them as distinct programs.
Accurate documentation and coding are important because quality measures rely on reliable clinical data, but CDI activity must remain focused on accurately representing the clinical record rather than manipulating quality metrics.
CCDS Reference Topics: HAC Reduction Program; PSI 90; HAI measures; quality payment; hospital performance.
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NEW QUESTION # 48
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