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| Section | Weight | Objectives |
|---|---|---|
| Topic 1: Healthcare facility CDI program analysis | 8.33% | - CDI program forecasting - Provider response rates - PEPPER data - Tracking and trending physician, department, and hospital performance - CC/MCC capture - Case mix index (CMI) - Publicly reported data - Hospital Value-Based Purchasing measures - High-frequency DRGs - CDI specialist productivity metrics - Basic computer and software application skills - Patient Safety Indicators - Physician performance measurement - Hospital-specific financial data - Severity of illness and risk of mortality |
| Topic 2: Healthcare regulations, reimbursement, and documentation requirements related to the IPPS | 12.5% | - Major complication/comorbidity (MCC) - Inpatient admission criteria and CMS Two-Midnight Rule - Documentation and medical necessity of setting - Documentation impact on IPPS reimbursement - Coding and billing practices vulnerable to denial - Case mix index (CMI) - IPPS and its updates and revisions - Medicare Severity Diagnosis Related Groups (MS-DRGs) - Medicare contractors and their impact on CDI - Principal diagnosis and medical necessity - Complication/comorbidity (CC) - Medical staff and clinical staff documentation responsibilities |
| Topic 3: Medical record documentation | 19.17% | - Translating clinical indicators into compliant queries - Situations in which queries are not appropriate - ACDIS/AHIMA Guidelines for Achieving a Compliant Query Practice - Addressing diagnoses without clinical support - When a physician query is warranted - Types of physician queries - Compliant and noncompliant queries - Provider role and diagnosis code assignment - Documentation requiring clarification - Physician query formats - Health record elements used for diagnosis and procedure code assignment - Clinical indicators |
| Topic 4: Official Guidelines for Coding and Reporting | 14.17% | - Coding guidelines for principal diagnosis selection - Discharge dispositions and transfers - Official Guidelines for Coding and Reporting updates - Principal diagnosis assignment - Present on admission indicators - AHA Coding Clinic - Hospital-acquired conditions - Secondary diagnosis assignment - Working DRG assignment for multiple diagnoses |
| Topic 5: Communication skills | 9.17% | - Physician education forms and tools - Reconciling CDI working DRGs with final coded DRGs - Effective and non-confrontational physician communication - Verbal versus written physician communication - Roles and responsibilities of CDI specialists - Educational presentations for healthcare departments and administration - Roles and responsibilities of coders working with CDI departments |
| Topic 6: Anatomy and physiology, pathophysiology, pharmacology, and medical terminology | 19.17% | - Injuries, poisonings, and toxic effects of drugs - Diseases and disorders of the respiratory system - Clinical indicators and query opportunities by Major Diagnostic Category - Diagnostic tests as clinical indicators - Diseases and disorders of the blood and blood-forming organs and immunological disorders - Standard medical abbreviations - Diseases and disorders of the hepatobiliary system - Diseases and disorders of the musculoskeletal system - Mental diseases and disorders - Diseases and disorders of the kidney and urinary tract - Diseases and disorders of the digestive system - Alcohol/drug use and alcohol/drug-induced organic brain disorders - Pharmaceuticals and disease processes - Medications as clinical indicators - Myeloproliferative diseases and disorders and poorly differentiated neoplasms - Endocrine, nutritional, and metabolic diseases and disorders - Diseases and disorders of the nervous system - Diseases and disorders of the circulatory system - Infectious and parasitic diseases - HIV infections - Diseases and disorders of the skin, subcutaneous tissue, and breast |
| Topic 7: Professionalism, ethics, and compliance | 9.17% | - Potential DRG creep - Compliance risks indicated by PEPPER - Leading queries - CDI department goals beyond reimbursement - DRG compliance initiatives - Medical record confidentiality |
| Topic 8: Impact of reportable diagnoses on quality of care | 8.33% | - CDI impact on Hospital Value-Based Purchasing - Mortality reviews and observed/expected ratios - Healthcare-associated infections and complication codes - Hospital Readmissions Reduction Program - Documentation and code assignment impact on mortality index - Quality data from record abstraction and claims data - Hospital Inpatient Quality Reporting Program - Patient Safety Indicators - Hospital Value-Based Purchasing - Coded data elements affecting Patient Safety Indicators - Hospital-Acquired Condition Reduction Program - 30-day mortality measures |
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NEW QUESTION # 141
A patient with dysphagia after a recent stroke develops fever, hypoxia, and a right lower-lobe infiltrate. The physician documents "pneumonia." Speech therapy documents repeated aspiration with oral intake. What is the MOST appropriate CDI action?
Answer: C
Explanation:
The record presents a legitimate opportunity to clarify the type or etiology of pneumonia, particularly whether aspiration contributed to the pulmonary infection. Dysphagia following stroke, documented aspiration during oral intake, fever, hypoxia, and a dependent-lobe infiltrate form a clinically relevant pattern.
However, the CDI specialist cannot independently convert unspecified pneumonia into aspiration pneumonia.
Likewise, the speech-language pathologist can provide valuable clinical evidence regarding swallowing dysfunction and aspiration risk, but that documentation does not independently establish the medical diagnosis of aspiration pneumonia for coding purposes.
A compliant query should objectively present the pertinent indicators and allow the provider to identify aspiration pneumonia, another pneumonia type, pneumonitis, another condition, or inability to determine.
Automatically assigning both bacterial and aspiration pneumonia would also be inappropriate because neither bacterial etiology nor a separate second pneumonia diagnosis has been established.
The current ACDIS/AHIMA guidance emphasizes that queries should arise from the clinical record and preserve the provider's independent judgment rather than directing a preferred diagnosis.
CCDS Reference Topics: Pneumonia specificity; aspiration; dysphagia; interdisciplinary documentation; compliant query development.
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NEW QUESTION # 142
A CDI specialist's working MS-DRG differs from the final coder-assigned MS-DRG in 18% of reviewed cases. What is the BEST initial management response?
Answer: B
Explanation:
A significant mismatch rate should trigger structured CDI/coding reconciliation, not an assumption that either department is wrong.
Working MS-DRGs are provisional. Final coding may change because of discharge-summary diagnoses, operative reports, pathology results, late physician clarification, Coding Clinic guidance, sequencing conventions, final procedure coding, CC/MCC exclusions, or other grouper logic unavailable during the concurrent CDI review.
The manager should categorize mismatch causes. Useful categories include principal-diagnosis differences, missed secondary diagnoses, procedure-code differences, coding-guideline interpretation, query results, discharge documentation, and technical grouper issues.
Patterns can then identify whether education is needed for CDI specialists, coding professionals, physicians, or multiple groups.
Requiring coding staff to adopt the CDI working DRG would undermine coding independence and final coding accountability. Excluding mismatches from metrics would conceal an important quality indicator.
CMS confirms that the FY 2026 MS-DRG Definitions Manual contains the complete grouper logic for Version 43.1, making current grouper rules essential when evaluating discrepancies.
CCDS Reference Topics: MS-DRG reconciliation; CDI/coder agreement; program analysis; education; grouper logic.
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NEW QUESTION # 143
A CDI program plans to develop a policy for addressing diagnoses that require clinical validation. According to the Guidelines for Achieving a Compliant Query Practice, which of the following should be addressed in the policy?
Answer: A
Explanation:
A compliant clinical-validation process should include a defined escalation process. The AHIMA/ACDIS query guidance specifically recommends organizational query policies that address escalation when a query remains unanswered or when documentation and clinical-validation concerns cannot be resolved through the ordinary workflow. Escalation may involve CDI or coding leadership, a physician advisor, the chief medical officer, or other designated personnel according to organizational policy.
Option A is inappropriate because simply coding every documented diagnosis without addressing significant clinical-support concerns undermines data integrity and increases denial and compliance risk. Option B is also too absolute. Coding professionals cannot independently substitute their clinical judgment for that of the responsible provider; unclear or potentially unsupported diagnoses should be addressed through an established clarification and validation process. Option D is incorrect because queries may appropriately occur concurrently or retrospectively depending on the circumstances and organizational workflow.
The goal of clinical validation is not to force removal or confirmation of a diagnosis. It is to ensure that the provider has an opportunity to clarify whether the diagnosis accurately represents the patient's clinical condition and to document supporting reasoning where appropriate.
CCDS Reference Topics: Professionalism, ethics, and compliance; clinical validation; compliant query policies; escalation procedures.
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NEW QUESTION # 144
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: C
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 # 145
Under the Inpatient Prospective Payment System, the PACT rule affects MS-DRG payment. PACT is an acronym for which of the following?
Answer: D
Explanation:
PACT stands for Post-Acute Care Transfer. The PACT policy is part of Medicare's IPPS transfer-payment framework and can modify the normal full MS-DRG payment when a qualifying inpatient stay ends with an early transfer or discharge to specified post-acute settings.
CMS applies transfer-payment methodology when applicable conditions are met, including circumstances involving selected discharges to skilled nursing facilities, inpatient rehabilitation facilities, long-term care hospitals, psychiatric facilities, and certain home-health arrangements. For home health, the timing and relationship of post-discharge care can be relevant.
The policy exists because a short acute-care hospitalization followed by transfer to another care setting may not involve the same hospital resource utilization as a conventional discharge completing the expected course of inpatient treatment. Accordingly, the transferring hospital may receive a calculated transfer payment rather than the unrestricted full MS-DRG amount.
For CDI professionals, PACT illustrates why accurate discharge disposition and documentation can affect reimbursement even when the principal diagnosis, procedures, CCs, and MCCs are correctly captured.
CCDS Reference Topics: IPPS; MS-DRG reimbursement; discharge disposition; transfer payment policy.
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NEW QUESTION # 146
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