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| Section | Weight | Objectives |
|---|---|---|
| Topic 1: Professionalism, ethics, and compliance | 9.17% | - CDI department goals beyond reimbursement - Potential DRG creep - Medical record confidentiality - Compliance risks indicated by PEPPER - DRG compliance initiatives - Leading queries |
| Topic 2: Anatomy and physiology, pathophysiology, pharmacology, and medical terminology | 19.17% | - Clinical indicators and query opportunities by Major Diagnostic Category - Medications as clinical indicators - Mental diseases and disorders - Pharmaceuticals and disease processes - Endocrine, nutritional, and metabolic diseases and disorders - Diseases and disorders of the digestive system - Infectious and parasitic diseases - Diseases and disorders of the blood and blood-forming organs and immunological disorders - Diseases and disorders of the hepatobiliary system - Standard medical abbreviations - Injuries, poisonings, and toxic effects of drugs - HIV infections - Alcohol/drug use and alcohol/drug-induced organic brain disorders - Diseases and disorders of the kidney and urinary tract - Diseases and disorders of the musculoskeletal system - Diagnostic tests as clinical indicators - Myeloproliferative diseases and disorders and poorly differentiated neoplasms - Diseases and disorders of the skin, subcutaneous tissue, and breast - Diseases and disorders of the nervous system - Diseases and disorders of the respiratory system - Diseases and disorders of the circulatory system |
| Topic 3: Impact of reportable diagnoses on quality of care | 8.33% | - Patient Safety Indicators - Hospital Readmissions Reduction Program - Documentation and code assignment impact on mortality index - Hospital Inpatient Quality Reporting Program - Healthcare-associated infections and complication codes - Hospital-Acquired Condition Reduction Program - Coded data elements affecting Patient Safety Indicators - 30-day mortality measures - Quality data from record abstraction and claims data - CDI impact on Hospital Value-Based Purchasing - Hospital Value-Based Purchasing - Mortality reviews and observed/expected ratios |
| Topic 4: Official Guidelines for Coding and Reporting | 14.17% | - Official Guidelines for Coding and Reporting updates - Present on admission indicators - AHA Coding Clinic - Coding guidelines for principal diagnosis selection - Secondary diagnosis assignment - Working DRG assignment for multiple diagnoses - Hospital-acquired conditions - Principal diagnosis assignment - Discharge dispositions and transfers |
| Topic 5: Healthcare facility CDI program analysis | 8.33% | - Case mix index (CMI) - Patient Safety Indicators - CDI specialist productivity metrics - High-frequency DRGs - Physician performance measurement - Basic computer and software application skills - Provider response rates - Tracking and trending physician, department, and hospital performance - CDI program forecasting - Hospital Value-Based Purchasing measures - CC/MCC capture - PEPPER data - Hospital-specific financial data - Severity of illness and risk of mortality - Publicly reported data |
| Topic 6: Medical record documentation | 19.17% | - ACDIS/AHIMA Guidelines for Achieving a Compliant Query Practice - Health record elements used for diagnosis and procedure code assignment - Compliant and noncompliant queries - When a physician query is warranted - Situations in which queries are not appropriate - Clinical indicators - Types of physician queries - Documentation requiring clarification - Translating clinical indicators into compliant queries - Physician query formats - Addressing diagnoses without clinical support - Provider role and diagnosis code assignment |
| Topic 7: Healthcare regulations, reimbursement, and documentation requirements related to the IPPS | 12.5% | - Case mix index (CMI) - Documentation impact on IPPS reimbursement - Inpatient admission criteria and CMS Two-Midnight Rule - Principal diagnosis and medical necessity - Medicare Severity Diagnosis Related Groups (MS-DRGs) - Major complication/comorbidity (MCC) - Documentation and medical necessity of setting - Coding and billing practices vulnerable to denial - Complication/comorbidity (CC) - Medicare contractors and their impact on CDI - Medical staff and clinical staff documentation responsibilities - IPPS and its updates and revisions |
| Topic 8: Communication skills | 9.17% | - Roles and responsibilities of CDI specialists - Verbal versus written physician communication - Reconciling CDI working DRGs with final coded DRGs - Roles and responsibilities of coders working with CDI departments - Effective and non-confrontational physician communication - Educational presentations for healthcare departments and administration - Physician education forms and tools |
>> Certification CCDS Test Answers <<
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NEW QUESTION # 87
A CDI specialist identifies fever, leukocytosis, tachycardia, positive blood cultures, and IV antibiotic treatment. No infectious diagnosis has been documented. Which query approach is MOST compliant?
Answer: A
Explanation:
The most compliant approach is to present the patient-specific clinical indicators objectively and request clarification using clinically reasonable choices without predetermining the diagnosis.
Neither the CDI specialist nor coder independently diagnoses sepsis from fever, leukocytosis, tachycardia, cultures, or antibiotic therapy. These findings create a legitimate clarification opportunity, but the responsible provider must determine whether the patient has sepsis, bacteremia, a localized infection, contamination, another condition, or no definitive diagnosis.
Option A is leading because it instructs the provider to document a specific diagnosis. Option B is problematic because a yes/no format would effectively introduce a new diagnosis that has not previously been documented. Option D violates basic coding principles because treatment alone does not establish a provider diagnosis.
The August 2026 ACDIS/AHIMA guidance is the current foundational standard for compliant query practice and supersedes earlier versions. It applies across inpatient and other healthcare environments and emphasizes defensible documentation clarification processes.
CCDS Reference Topics: Compliant queries; missing diagnosis; multiple-choice queries; clinical indicators; provider independence.
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NEW QUESTION # 88
Based on the AHIMA/ACDIS Practice Brief Guidelines for Achieving a Compliant Query Practice, a leading query is one that:
Answer: A
Explanation:
A query becomes problematic when it directs or influences the provider toward a diagnosis that is not supported by the patient's clinical record. Therefore, option C most accurately represents the leading-query concept in this answer set. A compliant query must be based on patient-specific clinical indicators and must preserve the provider's independent clinical judgment.
A multiple-choice query may include a diagnosis not previously documented when that diagnosis is supported by the clinical indicators and when reasonable alternatives are also offered. ACDIS/AHIMA guidance has specifically recognized that presenting a clinically supported new diagnosis among neutral choices does not automatically make the query leading.
Likewise, the timing of a query while a provider is documenting does not make it leading. Cause-and-effect clarification may also be addressed using an appropriate query format when both conditions are documented and the relationship remains uncertain.
The current 2026 ACDIS/AHIMA Guidelines for Achieving a Compliant Query Practice supersede the prior versions and continue to establish compliant provider-query practice as a foundational CDI standard. Queries must be clinically supported, noncoercive, and constructed without reference to reimbursement or other desired outcomes.
CCDS Reference Topics: Leading queries; clinical indicators; compliant query construction; provider independence.
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NEW QUESTION # 89
A CDI program reports the following monthly results:
- Provider response rate: 97%
- Provider agreement rate: 84%
- Queries issued after discharge: 38%
- CDI/coder agreement: 96%
Which metric presents the clearest opportunity to improve concurrent CDI workflow?
Answer: B
Explanation:
The 38% post-discharge query rate represents the clearest workflow opportunity because a large proportion of clarification is occurring after the concurrent hospitalization period.
A 97% provider response rate reflects strong physician participation, while a 96% CDI/coder agreement rate indicates substantial alignment between concurrent CDI review and final coding. An 84% agreement rate is not inherently problematic because providers must remain free to disagree with a query based on their clinical judgment.
A high retrospective-query percentage can indicate that cases are being reviewed too late, that certain documentation opportunities are not recognized during hospitalization, that discharge documentation introduces unresolved diagnoses, or that staffing/workflow does not adequately prioritize cases before discharge.
A CDI manager should drill further into the metric by service line, query type, day of stay, weekday/weekend discharge, provider group, and reason for retrospective clarification. This analysis helps distinguish unavoidable retrospective queries from remediable process problems.
The objective is not to eliminate every post-discharge query. Some documentation issues become apparent only after final testing, pathology, procedures, or discharge summaries are completed.
CCDS Reference Topics: CDI program metrics; concurrent versus retrospective review; workflow analysis; performance improvement.
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NEW QUESTION # 90
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: A
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 # 91
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 # 92
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