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| Section | Weight | Objectives |
|---|---|---|
| Healthcare facility CDI program analysis | 8.33% | - CDI specialist productivity metrics - CC/MCC capture - Patient Safety Indicators - PEPPER data - Provider response rates - Hospital-specific financial data - High-frequency DRGs - CDI program forecasting - Severity of illness and risk of mortality - Case mix index (CMI) - Basic computer and software application skills - Physician performance measurement - Hospital Value-Based Purchasing measures - Tracking and trending physician, department, and hospital performance - Publicly reported data |
| Official Guidelines for Coding and Reporting | 14.17% | - Working DRG assignment for multiple diagnoses - Hospital-acquired conditions - Principal diagnosis assignment - Official Guidelines for Coding and Reporting updates - Discharge dispositions and transfers - Coding guidelines for principal diagnosis selection - Secondary diagnosis assignment - Present on admission indicators - AHA Coding Clinic |
| Communication skills | 9.17% | - Educational presentations for healthcare departments and administration - Verbal versus written physician communication - Reconciling CDI working DRGs with final coded DRGs - Physician education forms and tools - Roles and responsibilities of CDI specialists - Roles and responsibilities of coders working with CDI departments - Effective and non-confrontational physician communication |
| Medical record documentation | 19.17% | - Situations in which queries are not appropriate - Types of physician queries - Provider role and diagnosis code assignment - Physician query formats - Addressing diagnoses without clinical support - Translating clinical indicators into compliant queries - Clinical indicators - Compliant and noncompliant queries - Documentation requiring clarification - ACDIS/AHIMA Guidelines for Achieving a Compliant Query Practice - When a physician query is warranted - Health record elements used for diagnosis and procedure code assignment |
| Healthcare regulations, reimbursement, and documentation requirements related to the IPPS | 12.5% | - Medicare contractors and their impact on CDI - Inpatient admission criteria and CMS Two-Midnight Rule - Complication/comorbidity (CC) - Documentation and medical necessity of setting - Medical staff and clinical staff documentation responsibilities - Medicare Severity Diagnosis Related Groups (MS-DRGs) - Principal diagnosis and medical necessity - Documentation impact on IPPS reimbursement - Case mix index (CMI) - IPPS and its updates and revisions - Major complication/comorbidity (MCC) - Coding and billing practices vulnerable to denial |
| 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 |
| Impact of reportable diagnoses on quality of care | 8.33% | - 30-day mortality measures - Patient Safety Indicators - Hospital Value-Based Purchasing - Hospital Readmissions Reduction Program - CDI impact on Hospital Value-Based Purchasing - Mortality reviews and observed/expected ratios - Hospital-Acquired Condition Reduction Program - Hospital Inpatient Quality Reporting Program - Coded data elements affecting Patient Safety Indicators - Documentation and code assignment impact on mortality index - Healthcare-associated infections and complication codes - Quality data from record abstraction and claims data |
| Anatomy and physiology, pathophysiology, pharmacology, and medical terminology | 19.17% | - Mental diseases and disorders - Myeloproliferative diseases and disorders and poorly differentiated neoplasms - Diseases and disorders of the digestive system - Diseases and disorders of the respiratory system - Standard medical abbreviations - Injuries, poisonings, and toxic effects of drugs - Clinical indicators and query opportunities by Major Diagnostic Category - Pharmaceuticals and disease processes - Diseases and disorders of the skin, subcutaneous tissue, and breast - Diseases and disorders of the nervous system - Alcohol/drug use and alcohol/drug-induced organic brain disorders - Endocrine, nutritional, and metabolic diseases and disorders - HIV infections - Diseases and disorders of the musculoskeletal system - Diseases and disorders of the hepatobiliary system - Diseases and disorders of the kidney and urinary tract - Diseases and disorders of the blood and blood-forming organs and immunological disorders - Diagnostic tests as clinical indicators - Medications as clinical indicators - Infectious and parasitic diseases - Diseases and disorders of the circulatory system |
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NEW QUESTION # 75
A physician documents obesity. A registered dietitian records a BMI of 38.4 kg/m². Which statement is MOST accurate?
Answer: A
NEW QUESTION # 76
Which CMS program can reduce an eligible hospital's Medicare base operating DRG payments by as much as
3% because of excess readmissions?
Answer: C
Explanation:
The Hospital Readmissions Reduction Program (HRRP) reduces payments to applicable hospitals with excess readmissions for specified conditions and procedures. CMS calculates a payment adjustment factor ranging from 1.0 to 0.97, meaning the maximum reduction is 3%.
The adjustment applies to applicable Medicare fee-for-service base operating DRG payments rather than solely to the readmission cases themselves.
This differs from the HAC Reduction Program, which applies a 1% reduction to hospitals in the worst- performing quartile based on defined hospital-acquired-condition measures. Hospital Value-Based Purchasing uses another methodology in which 2% of participating hospitals' base operating DRG payments funds value- based incentive payments.
For CDI professionals, readmission programs demonstrate how clinical documentation can influence more than individual MS-DRG reimbursement. Accurate documentation of comorbidities, principal diagnoses, complications, discharge circumstances, and disease severity contributes to reliable risk-adjusted data.
However, CDI intervention must remain focused on clinical accuracy rather than attempting to alter readmission metrics through unsupported diagnoses.
CCDS Reference Topics: HRRP; readmissions; quality reimbursement; IPPS; risk adjustment.
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NEW QUESTION # 77
Respiratory failure is documented in a patient's initial progress notes. There are no clinical indicators in the record to support this diagnosis. According to the AHIMA/ACDIS Practice Brief Guidelines for Achieving a Compliant Query Practice, the MOST appropriate action by the CDI specialist is which of the following?
Answer: B
Explanation:
This scenario requires a clinical validation query. The diagnosis of respiratory failure is documented, but the remainder of the record lacks clinical evidence supporting it. CDI should not automatically accept the diagnosis solely because it appears in a progress note, nor should the specialist unilaterally remove or invalidate the provider's diagnosis.
The appropriate process is to present relevant patient-specific clinical information objectively and ask the responsible provider to clarify whether respiratory failure remains clinically appropriate. A compliant validation query should permit the provider to confirm the diagnosis, document another condition, indicate that it was ruled out, or provide another clinically appropriate response.
Looking only for CPAP documentation is inadequate because CPAP can be used for multiple conditions and its presence or absence does not independently determine whether respiratory failure exists. Similarly, simply refusing to code the diagnosis without seeking clarification bypasses the provider's clinical judgment and the organization's validation process.
The 2026 ACDIS/AHIMA query guidance is now the current foundational standard and supersedes earlier versions of the practice brief.
CCDS Reference Topics: Clinical validation; compliant querying; unsupported diagnoses; documentation integrity.
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NEW QUESTION # 78
A patient with colon cancer is admitted solely for transfusion and management of anemia caused directly by the malignancy. No chemotherapy-related adverse effect is involved. Which condition is sequenced first?
Answer: C
Explanation:
When the admission is for management of anemia associated directly with the malignancy, and treatment is directed only at the anemia, the malignancy is sequenced as principal diagnosis, followed by the appropriate anemia code.
The FY 2026 Official Guidelines specifically distinguish malignancy-associated anemia from anemia caused by chemotherapy. For anemia associated with the malignancy, the neoplasm is sequenced first. For anemia resulting from an adverse effect of chemotherapy or immunotherapy, the anemia code is sequenced first.
This distinction makes documentation of anemia etiology essential. Phrases such as "anemia in cancer patient" may not clearly establish whether anemia is attributable to malignancy, chemotherapy, bleeding, nutritional deficiency, chronic kidney disease, or another process.
An encounter code for transfusion does not replace the principal-diagnosis rules for an inpatient hospitalization when the underlying reason for treatment is established.
Likewise, weakness is a symptom and would not supersede the definitive documented cancer-related anemia.
CDI professionals should therefore look beyond the fact that transfusion occurred and identify whether the medical record clearly establishes the cause of the anemia.
CCDS Reference Topics: Neoplasm-related anemia; principal diagnosis; sequencing; chemotherapy versus malignancy; medical record specificity.
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NEW QUESTION # 79
Two MS-DRGs have relative weights of 0.85 and 2.10. Which statement is MOST accurate?
Answer: A
Explanation:
An MS-DRG relative weight principally represents relative expected resource consumption. Therefore, a DRG with a relative weight of 2.10 is associated with greater average resource intensity than one with a relative weight of 0.85.
The weight does not determine the hospital's billed charges, nor is it a direct mortality score. Clinically complex patients may often fall into higher-weight DRGs because they require more resources, but resource intensity, severity of illness, and risk of mortality are conceptually distinct.
The relative weight contributes to IPPS payment calculations when multiplied through the applicable standardized-payment methodology and adjusted by hospital-specific factors and other payment rules.
CMS publishes current MS-DRG weighting factors as part of the FY 2026 IPPS Final Rule materials.
For CDI professionals, understanding relative weight helps explain why accurate diagnoses and procedures can influence reimbursement. However, reimbursement consequences must never become the justification for obtaining unsupported documentation. The objective remains accurate representation of the patient's clinical condition and resources required.
CCDS Reference Topics: Relative weight; resource consumption; IPPS; MS-DRG payment; severity concepts.
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NEW QUESTION # 80
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