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| Section | Weight | Objectives |
|---|---|---|
| Professionalism, ethics, and compliance | 9.17% | - DRG compliance initiatives - Potential DRG creep - Leading queries - CDI department goals beyond reimbursement - Medical record confidentiality - Compliance risks indicated by PEPPER |
| Communication skills | 9.17% | - Roles and responsibilities of CDI specialists - Roles and responsibilities of coders working with CDI departments - Verbal versus written physician communication - Educational presentations for healthcare departments and administration - Physician education forms and tools - Reconciling CDI working DRGs with final coded DRGs - Effective and non-confrontational physician communication |
| Impact of reportable diagnoses on quality of care | 8.33% | - Hospital Inpatient Quality Reporting Program - Hospital-Acquired Condition Reduction Program - Hospital Readmissions Reduction Program - Healthcare-associated infections and complication codes - CDI impact on Hospital Value-Based Purchasing - Mortality reviews and observed/expected ratios - 30-day mortality measures - Quality data from record abstraction and claims data - Hospital Value-Based Purchasing - Documentation and code assignment impact on mortality index - Patient Safety Indicators - Coded data elements affecting Patient Safety Indicators |
| Healthcare regulations, reimbursement, and documentation requirements related to the IPPS | 12.5% | - Inpatient admission criteria and CMS Two-Midnight Rule - Documentation and medical necessity of setting - Principal diagnosis and medical necessity - IPPS and its updates and revisions - Case mix index (CMI) - Medicare contractors and their impact on CDI - Major complication/comorbidity (MCC) - Medical staff and clinical staff documentation responsibilities - Medicare Severity Diagnosis Related Groups (MS-DRGs) - Documentation impact on IPPS reimbursement - Coding and billing practices vulnerable to denial - Complication/comorbidity (CC) |
| Anatomy and physiology, pathophysiology, pharmacology, and medical terminology | 19.17% | - Myeloproliferative diseases and disorders and poorly differentiated neoplasms - Infectious and parasitic diseases - Diseases and disorders of the musculoskeletal system - Diseases and disorders of the circulatory system - Endocrine, nutritional, and metabolic diseases and disorders - Diseases and disorders of the blood and blood-forming organs and immunological disorders - Diseases and disorders of the digestive system - HIV infections - Mental diseases and disorders - Alcohol/drug use and alcohol/drug-induced organic brain disorders - Diseases and disorders of the hepatobiliary system - Medications as clinical indicators - Standard medical abbreviations - Clinical indicators and query opportunities by Major Diagnostic Category - Diseases and disorders of the skin, subcutaneous tissue, and breast - Diseases and disorders of the respiratory system - Pharmaceuticals and disease processes - Diseases and disorders of the kidney and urinary tract - Diagnostic tests as clinical indicators - Injuries, poisonings, and toxic effects of drugs - Diseases and disorders of the nervous system |
| Healthcare facility CDI program analysis | 8.33% | - Provider response rates - Hospital-specific financial data - Physician performance measurement - CC/MCC capture - CDI specialist productivity metrics - Publicly reported data - PEPPER data - Basic computer and software application skills - Case mix index (CMI) - Tracking and trending physician, department, and hospital performance - Hospital Value-Based Purchasing measures - Patient Safety Indicators - CDI program forecasting - High-frequency DRGs - Severity of illness and risk of mortality |
| Medical record documentation | 19.17% | - Addressing diagnoses without clinical support - Health record elements used for diagnosis and procedure code assignment - Situations in which queries are not appropriate - Translating clinical indicators into compliant queries - Physician query formats - Clinical indicators - Types of physician queries - Documentation requiring clarification - Compliant and noncompliant queries - Provider role and diagnosis code assignment - When a physician query is warranted - ACDIS/AHIMA Guidelines for Achieving a Compliant Query Practice |
| Official Guidelines for Coding and Reporting | 14.17% | - Hospital-acquired conditions - Coding guidelines for principal diagnosis selection - Present on admission indicators - Secondary diagnosis assignment - Principal diagnosis assignment - Official Guidelines for Coding and Reporting updates - Working DRG assignment for multiple diagnoses - Discharge dispositions and transfers - AHA Coding Clinic |
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NEW QUESTION # 144
A CDI specialist sends a compliant query. The physician answers "other-viral syndrome" and supports the diagnosis in the progress note. The queried diagnosis would have been an MCC. What should the CDI specialist do?
Answer: C
Explanation:
The CDI specialist should accept the physician's clinically supported response. Querying is intended to clarify documentation, not to obtain a predetermined diagnosis or reimbursement result.
A compliant query should preserve the provider's independent clinical judgment. The physician may select one of the offered choices, document another diagnosis, rule out the suspected condition, or state that the diagnosis cannot be determined.
The fact that a different answer would qualify as an MCC is irrelevant to whether the provider's response should be respected.
Repeatedly issuing the same query because the initial response does not increase reimbursement risks creating a coercive or leading process and undermines documentation integrity.
A follow-up query could be justified if materially new clinical information appears or if the response itself remains internally contradictory or incomplete. But disagreement with the financial consequence is not sufficient.
The August 2026 ACDIS/AHIMA guidelines supersede all previous versions and are the current foundational resource for compliant query processes across healthcare settings.
CCDS Reference Topics: Provider autonomy; query response; MCC neutrality; ethical CDI practice; compliant querying.
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NEW QUESTION # 145
The table below shows physician performance:
Which of the following physicians will have the most favorable mortality rate on a public website, such as Healthgrades.com?
Answer: A
Explanation:
Physician 4 has the most favorable risk-adjusted mortality rate, at 1.3, compared with Physician 1 at 1.5, Physician 2 at 2.0, and Physician 3 at 2.5. Although Physician 1 has fewer observed deaths and an observed mortality rate of 1.6%, public outcome comparisons commonly incorporate risk adjustment rather than relying solely on raw mortality. Risk adjustment attempts to account for differences in patient complexity, comorbid disease burden, demographic factors, and other characteristics that influence expected outcomes.
This is directly relevant to CDI because incomplete documentation of clinically significant comorbidities can understate patient severity and therefore adversely affect the expected mortality component of risk-adjusted performance calculations. Conversely, accurate documentation allows coded data to represent the actual severity and risk of the population being treated. Healthgrades specifically states that its mortality methodology adjusts for patient risk factors to permit more meaningful comparisons of clinical outcomes.
The CCDS content outline specifically requires knowledge of mortality indices, severity of illness/risk of mortality, physician performance, and the effect of documentation on publicly reported data.
CCDS Reference Topics: Impact of reportable diagnoses on quality of care; Healthcare facility CDI program analysis; mortality index and risk adjustment.
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NEW QUESTION # 146
A patient's hemoglobin decreases from 13.1 g/dL before surgery to 7.4 g/dL afterward. Estimated intraoperative blood loss is 1,200 mL, and the patient receives two units of packed red blood cells. The physician documents only "postoperative anemia." Which clarification is MOST appropriate?
Answer: D
Explanation:
The significant hemoglobin decline, documented surgical blood loss, and transfusion requirement create a strong clinical basis to clarify whether the patient has acute blood loss anemia or another form of postoperative anemia.
However, neither the hemoglobin value nor transfusion independently establishes the diagnosis. The provider must determine the clinical significance and etiology. A postoperative hemoglobin decline can reflect actual hemorrhage, hemodilution, preexisting anemia, expected procedural blood loss, or multiple factors.
A compliant query could present baseline and postoperative hemoglobin levels, estimated blood loss, transfusion, hemodynamic findings, and relevant treatment, then ask the provider to characterize the anemia.
The CDI specialist should also distinguish anemia from a postprocedural complication. Even if acute blood loss anemia is documented, that does not automatically mean a surgical complication occurred. Complication status may require separate provider clarification depending on the record.
Hemolytic anemia has a different pathophysiology involving red-cell destruction, while chronic iron deficiency cannot be inferred from the acute postoperative course.
CCDS Reference Topics: Acute blood loss anemia; postoperative documentation; transfusion; clinical indicators; complications of care.
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NEW QUESTION # 147
CMS identifies the complete logic used to assign inpatient cases to MS-DRGs in which FY 2026 resource?
Answer: D
Explanation:
The ICD-10 MS-DRG Definitions Manual contains the detailed grouper logic CMS uses for MS-DRG assignment. CMS states that the FY 2026 Definitions Manual files provide the complete documentation of ICD-10 MS-DRG grouper logic.
The manual organizes MS-DRGs by Major Diagnostic Category and includes the principal diagnoses, procedures, MCC/CC structure, exclusions, and other logic needed to understand how cases group.
As of September 2026, CMS identifies FY 2026 Version 43.1 as effective for discharges from April 1 through September 30, 2026. Version 44 begins October 1, 2026 for FY 2027.
The Physician Fee Schedule governs professional services and does not define inpatient MS-DRGs. HCAHPS concerns patient-experience measurement, while the National Correct Coding Initiative focuses primarily on coding edits designed to prevent inappropriate code combinations in other reimbursement contexts.
CDI specialists do not need to memorize every grouper pathway, but they should understand how principal diagnosis, secondary conditions, procedures, and CC/MCC classifications interact to determine the working and final MS-DRG.
CCDS Reference Topics: MS-DRG Definitions Manual; grouper logic; IPPS; current fiscal-year resources.
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NEW QUESTION # 148
A hospital's case is assigned to an MS-DRG with a relative weight of 2.0000. What does the relative weight primarily indicate?
Answer: B
Explanation:
An MS-DRG relative weight represents relative expected resource consumption, not a direct severity score or mortality probability. Therefore, a relative weight of approximately 2.0 means the MS-DRG is associated with roughly twice the resource intensity of the average case represented by the standardized reference point.
CMS calculates and recalibrates MS-DRG relative weights using national hospital data as part of IPPS rate setting. The FY 2026 final-rule materials include the MS-DRG weighting factors as well as supporting cost data used in the relative-weight methodology.
Clinically complex cases often consume more resources, so relative weight may correlate with severity.
However, it is not equivalent to a patient's severity-of-illness score or risk-of-mortality score. Likewise, hospitals do not simply multiply their billed charges based on the DRG weight. IPPS payment involves the standardized amount plus various adjustments, including wage index and other applicable payment factors.
For CDI, accurate documentation matters because diagnoses and procedures drive MS-DRG assignment, and the assigned MS-DRG carries its specific relative weight.
CCDS Reference Topics: IPPS; MS-DRG relative weight; resource consumption; reimbursement methodology.
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NEW QUESTION # 149
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