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| Section | Weight | Objectives |
|---|---|---|
| Topic 1: Quality, Risk Adjustment & Health Initiatives | 15% | - Risk adjustment models and documentation impact - Severity of Illness (SOI) / Risk of Mortality (ROM) - Quality reporting, public reporting, and compliance programs |
| Topic 2: Clinical Documentation Review & Query Practices | 20% | - Documentation gap identification and resolution - Concurrent and retrospective chart review methodologies - Query development, communication, and ethical standards |
| Topic 3: Healthcare Regulations, Reimbursement & Documentation Requirements – IPPS | 15% | - Medicare Severity Diagnostic Related Groups (MS-DRGs) - Documentation responsibilities of medical and clinical staff - Inpatient Prospective Payment System (IPPS) fundamentals |
| Topic 4: Clinical Knowledge & Disease Processes Application | 20% | - Clinical indicators, lab results, medications, diagnostic findings - Disease processes across body systems applied to chart review - Medical terminology, anatomy, physiology, pathophysiology |
| Topic 5: Coding Guidelines & Official Reporting Standards | 15% | - ICD-10-CM/PCS Official Guidelines for Coding and Reporting - AHIMA/ACDIS Guidelines for Compliant Query Practice - Coding integrity and compliant documentation practices |
| Topic 6: CDI Program Management & Professional Practice | 15% | - Provider education and training strategies - Ethics, HIPAA, and professional conduct - Program metrics, benchmarks, and performance measurement |
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NEW QUESTION # 67
A pregnant patient is admitted at 30 weeks' gestation with acute pyelonephritis complicating pregnancy.
Which general sequencing principle applies?
Answer: C
Explanation:
ICD-10-CM Chapter 15 codes generally have sequencing priority over codes from other chapters when a condition complicates pregnancy, childbirth, or the puerperium.
Therefore, when pyelonephritis complicates pregnancy, the appropriate obstetric complication code is generally sequenced first, with additional code(s) used as instructed to identify the specific infection or organism.
This principle is important because ordinary principal-diagnosis logic can be modified by chapter-specific instructions. CDI specialists working with obstetric cases therefore must determine whether the pregnancy affects management and whether the condition is documented as complicating pregnancy.
The only major exception would be when the provider specifically determines that the pregnancy is incidental to the encounter and the applicable coding requirements for incidental pregnancy are met.
A symptom code does not generally supersede an established definitive diagnosis. Likewise, the fact that an infection could occur outside pregnancy does not negate Chapter 15 sequencing when it is complicating the pregnancy.
Correct gestational-age documentation is also important because an additional code may be required to identify the specific week of gestation.
CCDS Reference Topics: Obstetric coding; Chapter 15; sequencing priority; infection in pregnancy; principal diagnosis.
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NEW QUESTION # 68
The amount of the IPPS Indirect Medical Education Adjustment is determined by teaching intensity as measured by the hospital's number of residents compared to:
Answer: D
Explanation:
Medicare's Indirect Medical Education (IME) adjustment uses the hospital's resident-to-bed ratio as the principal measure of teaching intensity. CMS explains that the IME adjustment factor is calculated using a hospital's ratio of residents to beds. Therefore, the correct answer is inpatient beds.
IME is an additional IPPS payment intended to recognize the higher indirect patient-care costs associated with operating an approved teaching program. These costs are distinguished from Direct Graduate Medical Education payments, which reimburse qualifying direct costs associated with residency training.
The number of admissions is not the denominator in the IME teaching-intensity calculation. Likewise, emergency-department beds are not simply combined with inpatient beds for the standard resident-to-bed ratio, and disproportionate-share payment rates represent a separate IPPS adjustment related principally to hospitals caring for substantial numbers of low-income patients.
For the CCDS examination, the important distinction is that IPPS reimbursement involves more than the base MS-DRG payment. Adjustments may include IME, disproportionate-share hospital provisions, wage-index effects, outlier payments, and other statutory mechanisms.
CCDS Reference Topics: IPPS reimbursement; teaching hospitals; IME adjustment; resident-to-bed ratio.
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NEW QUESTION # 69
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?
Answer: C
Explanation:
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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NEW QUESTION # 70
A hospital has 2,500 inpatient discharges and a cumulative MS-DRG relative weight of 4,375. What is the hospital's case mix index?
Answer: B
Explanation:
Case mix index is calculated as:
Total MS-DRG relative weights ÷ Total inpatient discharges
Therefore:
4,375 ÷ 2,500 = 1.75
The hospital's CMI is 1.75.
CMI provides an aggregate indication of the average relative resource intensity of the hospital's inpatient population. Because each MS-DRG carries a relative weight, hospitals treating larger numbers of complex medical or surgical cases typically have higher CMIs than hospitals treating less resource-intensive populations.
CMI is not a direct quality score and should not be interpreted as a pure measure of CDI performance. It can change because of service-line mix, surgical volume, patient acuity, transfers, annual MS-DRG recalibration, coding accuracy, documentation quality, and other operational changes.
CMS maintains the FY 2026 MS-DRG Definitions Manual and grouper logic, currently Version 43.1 for April 1 through September 30, 2026.
A CDI manager should therefore analyze unexpected CMI changes alongside service-line trends, query activity, coding reconciliation, procedure volumes, and diagnosis patterns.
CCDS Reference Topics: CMI; relative weights; CDI analytics; MS-DRGs; trend analysis.
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NEW QUESTION # 71
The attending physician documents acute respiratory failure. The patient has normal respiratory effort, oxygen saturation of 97% on room air, no supplemental oxygen requirement, and no ventilatory support. What is the MOST appropriate CDI action?
Answer: A
Explanation:
This is a classic clinical validation query scenario. A diagnosis has been documented, but the available clinical evidence appears inconsistent with or insufficient to support that diagnosis.
The CDI specialist should not independently delete acute respiratory failure, substitute another diagnosis, or direct coding personnel to disregard provider documentation without an appropriate clarification process.
Instead, the query should objectively present the relevant clinical findings-normal respiratory effort, room- air oxygenation, absence of escalating oxygen requirements, and absence of ventilatory support-and ask the provider to clarify the diagnosis.
The provider may confirm respiratory failure and document additional clinical reasoning, revise the diagnosis, identify another condition, or state that the diagnosis was ruled out. The CDI specialist's responsibility is to support record integrity, not to replace provider clinical judgment.
The official CCDS content outline specifically requires candidates to understand mechanisms for addressing diagnoses lacking clinical support and to distinguish compliant from noncompliant queries. The current 2026 ACDIS/AHIMA guidance is the foundational query-practice standard.
CCDS Reference Topics: Clinical validation; respiratory failure; unsupported diagnoses; compliant query practice; documentation integrity.
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NEW QUESTION # 72
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