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| Section | Weight | Objectives |
|---|---|---|
| Topic 1: Professionalism, ethics, and compliance | 9.17% | - Leading queries - Compliance risks indicated by PEPPER - Potential DRG creep - Medical record confidentiality - DRG compliance initiatives - CDI department goals beyond reimbursement |
| Topic 2: Healthcare facility CDI program analysis | 8.33% | - CDI program forecasting - Tracking and trending physician, department, and hospital performance - CC/MCC capture - Basic computer and software application skills - Hospital Value-Based Purchasing measures - Provider response rates - Physician performance measurement - Case mix index (CMI) - PEPPER data - Severity of illness and risk of mortality - CDI specialist productivity metrics - Publicly reported data - High-frequency DRGs - Patient Safety Indicators - Hospital-specific financial data |
| Topic 3: Healthcare regulations, reimbursement, and documentation requirements related to the IPPS | 12.5% | - Coding and billing practices vulnerable to denial - IPPS and its updates and revisions - Inpatient admission criteria and CMS Two-Midnight Rule - Principal diagnosis and medical necessity - Case mix index (CMI) - Medicare contractors and their impact on CDI - Major complication/comorbidity (MCC) - Complication/comorbidity (CC) - Medical staff and clinical staff documentation responsibilities - Documentation impact on IPPS reimbursement - Medicare Severity Diagnosis Related Groups (MS-DRGs) - Documentation and medical necessity of setting |
| Topic 4: Anatomy and physiology, pathophysiology, pharmacology, and medical terminology | 19.17% | - Diagnostic tests as clinical indicators - Diseases and disorders of the blood and blood-forming organs and immunological disorders - Pharmaceuticals and disease processes - Diseases and disorders of the kidney and urinary tract - Diseases and disorders of the nervous system - Medications as clinical indicators - Diseases and disorders of the hepatobiliary system - Clinical indicators and query opportunities by Major Diagnostic Category - Injuries, poisonings, and toxic effects of drugs - Diseases and disorders of the respiratory system - Alcohol/drug use and alcohol/drug-induced organic brain disorders - Endocrine, nutritional, and metabolic diseases and disorders - Myeloproliferative diseases and disorders and poorly differentiated neoplasms - Mental diseases and disorders - HIV infections - Diseases and disorders of the skin, subcutaneous tissue, and breast - Diseases and disorders of the circulatory system - Diseases and disorders of the musculoskeletal system - Infectious and parasitic diseases - Diseases and disorders of the digestive system - Standard medical abbreviations |
| Topic 5: Communication skills | 9.17% | - Physician education forms and tools - Reconciling CDI working DRGs with final coded DRGs - Verbal versus written physician communication - Educational presentations for healthcare departments and administration - Effective and non-confrontational physician communication - Roles and responsibilities of CDI specialists - Roles and responsibilities of coders working with CDI departments |
| Topic 6: Official Guidelines for Coding and Reporting | 14.17% | - Secondary diagnosis assignment - Principal diagnosis assignment - AHA Coding Clinic - Official Guidelines for Coding and Reporting updates - Coding guidelines for principal diagnosis selection - Hospital-acquired conditions - Present on admission indicators - Working DRG assignment for multiple diagnoses - Discharge dispositions and transfers |
| Topic 7: Medical record documentation | 19.17% | - ACDIS/AHIMA Guidelines for Achieving a Compliant Query Practice - Addressing diagnoses without clinical support - Compliant and noncompliant queries - When a physician query is warranted - Situations in which queries are not appropriate - Documentation requiring clarification - Health record elements used for diagnosis and procedure code assignment - Translating clinical indicators into compliant queries - Clinical indicators - Provider role and diagnosis code assignment - Physician query formats - Types of physician queries |
| Topic 8: Impact of reportable diagnoses on quality of care | 8.33% | - Healthcare-associated infections and complication codes - Coded data elements affecting Patient Safety Indicators - Hospital-Acquired Condition Reduction Program - Hospital Value-Based Purchasing - Mortality reviews and observed/expected ratios - Hospital Inpatient Quality Reporting Program - Hospital Readmissions Reduction Program - 30-day mortality measures - Quality data from record abstraction and claims data - Patient Safety Indicators - CDI impact on Hospital Value-Based Purchasing - Documentation and code assignment impact on mortality index |
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NEW QUESTION # 103
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 # 104
A CDI program is developing a query escalation policy. A clinically significant query remains unanswered despite normal reminders. Which action is MOST appropriate?
Answer: D
Explanation:
An unanswered clinically significant query should be managed through the organization's defined escalation process. The process may involve CDI leadership, coding leadership, a physician advisor, department leadership, or other designated personnel, depending on organizational policy.
Neither CDI nor coding may independently supply the missing diagnosis because diagnostic conclusions remain the provider's responsibility. Removing an unresolved query simply to accelerate billing can undermine documentation integrity and may create compliance problems.
Escalation policies should be standardized rather than applied only when a particular diagnosis affects reimbursement. Policies commonly address expected response time, reminder intervals, responsible escalation personnel, high-priority queries, retrospective queries, and final-bill procedures.
The 2026 ACDIS/AHIMA Guidelines for Achieving a Compliant Query Practice supersede prior versions and serve as the current foundational guidance for organizations establishing compliant query policies and procedures.
A mature escalation process balances timely claim completion with respect for provider workload and independent clinical judgment. Its purpose is obtaining complete and accurate documentation, not forcing agreement with a CDI-generated diagnosis.
CCDS Reference Topics: Query escalation; organizational policy; unanswered queries; compliance; provider responsibility.
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NEW QUESTION # 105
An MS-DRG family is divided into three severity levels: with MCC, with CC, and without CC/MCC.
Assuming all other grouper conditions are identical, which secondary diagnosis category generally results in the highest severity-level assignment?
Answer: D
Explanation:
An MCC-major complication or comorbidity-represents the highest secondary-diagnosis severity category within the standard three-tier MS-DRG hierarchy. CMS describes MCCs as diagnoses with the highest level of severity affecting hospital resource use, CCs as conditions with a moderate level, and non-CC diagnoses as the lowest severity level.
When an MS-DRG family is divided into "with MCC," "with CC," and "without CC/MCC," the presence of a qualifying MCC generally moves the case into the highest severity subdivision, assuming no exclusion or other grouper rule prevents that effect.
This does not mean every MCC always increases payment. Some secondary diagnoses are excluded as MCCs or CCs in particular circumstances because of principal-diagnosis exclusions or DRG-specific logic. CMS's FY 2026 Definitions Manual specifically contains exclusion lists and severity logic for such situations.
CDI specialists should understand MCC/CC logic to interpret working DRGs, but query activity must be driven by clinical accuracy rather than the financial value of a severity level.
CCDS Reference Topics: MS-DRGs; MCC; CC; severity subdivisions; resource utilization; reimbursement compliance.
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NEW QUESTION # 106
The physician evaluates a postoperative wound infection but states, "I cannot clinically determine whether the infection was already developing at admission or began after admission." Which POA indicator MOST accurately reflects this provider determination?
Answer: D
Explanation:
POA indicator W means the provider is clinically unable to determine whether the condition was present on admission. That is precisely what is documented in this scenario.
This must be distinguished from POA indicator U. U means the documentation is insufficient to determine POA status, whereas W reflects an actual clinical determination that the timing cannot be established even after appropriate assessment.
Indicator Y means the condition was present when the inpatient admission order occurred, while N means it was not present at that point.
This distinction matters because POA status contributes to CMS Hospital-Acquired Condition payment logic and hospital quality analyses. CDI specialists should attempt to obtain clarification when timing is unclear, but they must accept a legitimate provider determination that onset cannot clinically be established.
Not every ambiguous timeline should be forced into either Y or N. When clinical evidence truly cannot resolve the timing, W is an appropriate reporting outcome.
CMS maintains separate annual POA-exempt resources and HAC/POA coding information for the applicable fiscal year.
CCDS Reference Topics: POA indicators; W versus U; onset timing; HACs; inpatient coding.
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NEW QUESTION # 107
The documentation is insufficient to determine whether a reportable diagnosis was present at the time of inpatient admission. Which POA indicator represents this situation?
Answer: B
Explanation:
POA indicator U means that the documentation is insufficient to determine whether the condition was present on admission.
This is different from Y, which indicates that the condition was present when inpatient admission occurred, and N, which indicates that the condition was not present at admission. Indicator W is used when the provider is unable to clinically determine whether the condition was present at the time of inpatient admission.
The distinction between U and W is especially important. U reflects inadequacy of the documentation, whereas W reflects a clinical determination that the timing cannot be established despite appropriate evaluation.
CDI specialists should generally attempt to resolve unclear timing when clinically feasible before a case reaches final coding. Accurate POA assignment can influence CMS Hospital-Acquired Condition payment logic and quality measurement.
CMS publishes an annual list of diagnoses exempt from POA reporting and maintains the FY 2026 POA resources separately from the HAC code lists.
POA reporting focuses on the condition's status at inpatient admission, not merely when it was first documented or when diagnostic confirmation became available.
CCDS Reference Topics: POA indicators; U versus W; HACs; admission timing; inpatient reporting.
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NEW QUESTION # 108
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