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| Section | Weight | Objectives |
|---|---|---|
| Topic 1: Official Guidelines for Coding and Reporting | 14.17% | - Working DRG assignment for multiple diagnoses - Coding guidelines for principal diagnosis selection - Present on admission indicators - Hospital-acquired conditions - Principal diagnosis assignment - Discharge dispositions and transfers - Official Guidelines for Coding and Reporting updates - Secondary diagnosis assignment - AHA Coding Clinic |
| Topic 2: Healthcare facility CDI program analysis | 8.33% | - Provider response rates - Case mix index (CMI) - CC/MCC capture - CDI specialist productivity metrics - Hospital Value-Based Purchasing measures - Patient Safety Indicators - Hospital-specific financial data - CDI program forecasting - Tracking and trending physician, department, and hospital performance - Severity of illness and risk of mortality - High-frequency DRGs - Basic computer and software application skills - Physician performance measurement - Publicly reported data - PEPPER data |
| Topic 3: Professionalism, ethics, and compliance | 9.17% | - Leading queries - Medical record confidentiality - DRG compliance initiatives - Potential DRG creep - CDI department goals beyond reimbursement - Compliance risks indicated by PEPPER |
| Topic 4: Impact of reportable diagnoses on quality of care | 8.33% | - 30-day mortality measures - Healthcare-associated infections and complication codes - Hospital Value-Based Purchasing - Quality data from record abstraction and claims data - Hospital-Acquired Condition Reduction Program - Mortality reviews and observed/expected ratios - CDI impact on Hospital Value-Based Purchasing - Hospital Readmissions Reduction Program - Hospital Inpatient Quality Reporting Program - Patient Safety Indicators - Coded data elements affecting Patient Safety Indicators - Documentation and code assignment impact on mortality index |
| Topic 5: Communication skills | 9.17% | - Effective and non-confrontational physician communication - Verbal versus written physician communication - Educational presentations for healthcare departments and administration - Physician education forms and tools - Roles and responsibilities of coders working with CDI departments - Reconciling CDI working DRGs with final coded DRGs - Roles and responsibilities of CDI specialists |
| Topic 6: Healthcare regulations, reimbursement, and documentation requirements related to the IPPS | 12.5% | - Case mix index (CMI) - Documentation and medical necessity of setting - Principal diagnosis and medical necessity - Medical staff and clinical staff documentation responsibilities - Documentation impact on IPPS reimbursement - Complication/comorbidity (CC) - Medicare Severity Diagnosis Related Groups (MS-DRGs) - Medicare contractors and their impact on CDI - Coding and billing practices vulnerable to denial - Major complication/comorbidity (MCC) - Inpatient admission criteria and CMS Two-Midnight Rule - IPPS and its updates and revisions |
| Topic 7: Anatomy and physiology, pathophysiology, pharmacology, and medical terminology | 19.17% | - Clinical indicators and query opportunities by Major Diagnostic Category - HIV infections - Diseases and disorders of the digestive system - Diseases and disorders of the nervous system - Standard medical abbreviations - Infectious and parasitic diseases - Alcohol/drug use and alcohol/drug-induced organic brain disorders - Diagnostic tests as clinical indicators - Diseases and disorders of the kidney and urinary tract - Myeloproliferative diseases and disorders and poorly differentiated neoplasms - Endocrine, nutritional, and metabolic diseases and disorders - Diseases and disorders of the skin, subcutaneous tissue, and breast - Mental diseases and disorders - Diseases and disorders of the circulatory system - Injuries, poisonings, and toxic effects of drugs - Diseases and disorders of the blood and blood-forming organs and immunological disorders - Pharmaceuticals and disease processes - Diseases and disorders of the musculoskeletal system - Diseases and disorders of the hepatobiliary system - Medications as clinical indicators - Diseases and disorders of the respiratory system |
| Topic 8: Medical record documentation | 19.17% | - Documentation requiring clarification - When a physician query is warranted - Addressing diagnoses without clinical support - Physician query formats - Situations in which queries are not appropriate - ACDIS/AHIMA Guidelines for Achieving a Compliant Query Practice - Compliant and noncompliant queries - Types of physician queries - Clinical indicators - Health record elements used for diagnosis and procedure code assignment - Provider role and diagnosis code assignment - Translating clinical indicators into compliant queries |
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NEW QUESTION # 110
A hospital's mortality report shows 125 observed deaths and 100 expected deaths. The observed-to-expected mortality ratio is 1.25. Which interpretation is MOST accurate?
Answer: A
Explanation:
An observed-to-expected mortality ratio is calculated by dividing observed deaths by expected deaths. Here,
125 divided by 100 equals 1.25. Therefore, observed deaths are 25% higher than the number predicted by the risk-adjustment model.
A ratio of 1.0 indicates observed mortality equals expected mortality. A value below 1.0 indicates fewer observed deaths than predicted, while a value above 1.0 indicates more observed deaths than predicted.
The CDI implication is important. Expected mortality is influenced by the patient's documented disease burden and other variables used by the applicable risk-adjustment methodology. If clinically significant conditions are underdocumented, the coded record may fail to represent the patient's actual severity, potentially reducing calculated expected mortality.
However, CDI should never seek diagnoses solely to improve a mortality ratio. Each diagnosis must be clinically supported and accurately documented. A high ratio can reflect multiple factors-including clinical outcomes, case mix, documentation, coding, data quality, or model characteristics-and should trigger multidisciplinary analysis rather than automatic querying.
ACDIS includes mortality and severity/risk adjustment within CCDS competency expectations.
CCDS Reference Topics: O/E mortality; risk adjustment; severity documentation; quality outcomes.
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NEW QUESTION # 111
A CDI team identifies that orthopedic surgeons frequently document "postoperative anemia" without specifying whether blood loss is acute, expected, chronic, or clinically insignificant. What is the BEST educational strategy?
Answer: A
Explanation:
The strongest educational approach is targeted specialty-specific education using the surgeons' own documentation trends and realistic clinical examples. This addresses the recurring documentation problem while remaining clinically relevant to the audience.
Orthopedic surgeons do not need to become coding specialists. Education should instead explain which clinical distinctions matter-for example, whether anemia represents expected postoperative change, acute blood loss anemia, chronic anemia, or another diagnosis-and why accurate terminology improves the medical record.
Providing a long code list is unlikely to improve physician documentation behavior. Instructing surgeons to document acute blood loss anemia whenever hemoglobin decreases would be clinically inappropriate and could produce unsupported diagnoses. A postoperative hemoglobin decline may reflect hemodilution, expected surgical blood loss, chronic anemia, or other factors.
Stopping queries would leave meaningful ambiguities unresolved.
ACDIS/AHIMA query guidance emphasizes documentation accuracy and provider independence rather than reimbursement-focused diagnosis selection.
Successful physician education should be concise, clinically oriented, supported by service-line data, and reinforced when subsequent query trends demonstrate persistent problems.
CCDS Reference Topics: Physician education; communication; postoperative anemia; query trends; provider engagement.
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NEW QUESTION # 112
Which of the following diagnoses is classified as a major complication/comorbidity (MCC) under the FY
2026 MS-DRG system?
Answer: D
Explanation:
Severe protein-calorie malnutrition is the correct answer. This question is adapted from an official CCDS sample question published by ACDIS.
Under the FY 2026 MS-DRG Definitions Manual, E43, unspecified severe protein-calorie malnutrition, is classified as an MCC. In contrast, moderate and mild protein-calorie malnutrition codes are classified as CCs rather than MCCs.
An MCC can materially affect MS-DRG assignment when the applicable DRG family differentiates cases by MCC status and when no exclusion or other grouper rule prevents the effect. However, the financial effect is never sufficient justification for a query. Documentation must be clinically supported and reflect the patient's actual condition.
A dietitian may document detailed nutrition findings and malnutrition criteria, but the reportable diagnosis ordinarily requires documentation by the provider responsible for establishing diagnoses. Therefore, when strong nutritional indicators exist but the provider has not documented malnutrition, a compliant query may be appropriate.
For CCDS preparation, candidates should understand both the clinical characteristics of malnutrition and its coding/reimbursement classification.
CCDS Reference Topics: MCCs; malnutrition; MS-DRG methodology; documentation requirements; IPPS.
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NEW QUESTION # 113
Under the IPPS Post-Acute Care Transfer policy, which documentation element is particularly important because it can affect whether transfer-payment methodology applies?
Answer: B
Explanation:
Accurate discharge disposition is critical to application of the Post-Acute Care Transfer policy because the patient's destination after the acute inpatient stay can determine whether transfer-payment methodology applies.
Qualifying discharges to certain post-acute settings can be subject to transfer-payment rules when other criteria are met. These settings can include skilled nursing facilities and other specified post-acute arrangements, depending on applicable CMS requirements and the MS-DRG involved.
Therefore, an incorrectly documented discharge destination can affect reimbursement even when the diagnoses, procedures, and MS-DRG are otherwise accurate.
The PACT concept demonstrates why CDI and coding accuracy extend beyond diagnosis capture. The inpatient claim also relies on accurate demographic, procedural, discharge-status, and utilization information.
Dietary preference, physician experience, and the number of daily progress notes do not determine whether PACT methodology applies.
CDI specialists should recognize when conflicting documentation exists regarding whether a patient went home, to skilled nursing, rehabilitation, another acute facility, hospice, or another destination and collaborate with the appropriate departments to ensure the final record accurately reflects the actual disposition.
CCDS Reference Topics: PACT; discharge disposition; IPPS transfer rules; reimbursement; data integrity.
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NEW QUESTION # 114
Which statement BEST defines the principal diagnosis for an inpatient hospitalization?
Answer: D
Explanation:
The principal diagnosis is the condition established after study to be chiefly responsible for occasioning the patient's admission to the hospital for care. This is the UHDDS definition used in the ICD-10-CM Official Guidelines for inpatient principal-diagnosis selection.
"After study" is critical. The diagnosis initially suspected in the emergency department may change after diagnostic testing, consultation, treatment response, surgery, pathology, or other evaluation. The final principal diagnosis therefore may differ from the first diagnosis documented.
Relative weight does not determine principal diagnosis. A hospital cannot select a higher-paying condition merely because it produces a more favorable MS-DRG. Similarly, medication volume is not a principal- diagnosis criterion.
For CDI specialists, principal-diagnosis review requires understanding the circumstances surrounding admission, the diagnostic workup, final provider documentation, sequencing conventions, and any chapter- specific guidelines. When two conditions are documented and it is unclear which chiefly occasioned the admission, a provider query may be warranted.
The CCDS content outline specifically tests the principles and application of principal-diagnosis assignment.
CCDS Reference Topics: Principal diagnosis; UHDDS; inpatient sequencing; working MS-DRG.
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NEW QUESTION # 115
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