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| Section | Weight | Objectives |
|---|---|---|
| Topic 1: Official Guidelines for Coding and Reporting | 14.17% | - Principal and secondary diagnosis assignment - Coding guidelines, AHA Coding Clinic, HACs, and POA indicators |
| Topic 2: Healthcare facility CDI program analysis | 8.33% | - Data analysis, forecasting, and performance measurement - CDI productivity, provider response, CMI, and program metrics |
| Topic 3: Medical record documentation | 19.17% | - Documentation clarification and compliant physician queries - Documentation requirements and diagnosis or procedure code assignment |
| Topic 4: Communication skills | 9.17% | - Physician education and effective communication - CDI and coding roles and interdisciplinary collaboration |
| Topic 5: Anatomy and physiology, pathophysiology, pharmacology, and medical terminology | 19.17% | - Clinical conditions and clinical indicators - Anatomy, physiology, pathophysiology, pharmacology, and terminology |
| Topic 6: Healthcare regulations, reimbursement, and documentation requirements related to the IPPS | 12.5% | - IPPS, MS-DRGs, reimbursement, and medical necessity - CC/MCC, CMI, Medicare contractors, and compliance |
| Topic 7: Impact of reportable diagnoses on quality of care | 8.33% | - Mortality, severity of illness, and risk of mortality - Quality metrics, reporting programs, and financial impact |
| Topic 8: Professionalism, ethics, and compliance | 9.17% | - Query compliance, DRG creep, and audit risks - Confidentiality, DRG compliance, and ethical CDI practices |
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NEW QUESTION # 77
A CDI specialist has been asked to present a report to hospital administration that will demonstrate the CDI program's impact over time. Which of the following reports will BEST accomplish this?
Answer: D
Explanation:
A line graph showing Risk of Mortality (ROM) and Severity of Illness (SOI) by month provides the strongest evidence of program impact over time because it displays longitudinal trends. Hospital leadership can readily determine whether documented patient complexity and risk profiles are increasing, decreasing, or remaining stable and can correlate those trends with CDI interventions.
The CCDS content outline specifically requires CDI specialists to analyze program trends, use SOI/ROM and other program-performance methodologies, create forecasting data, evaluate hospital performance, and track metrics over time. A line graph is particularly appropriate because time is the independent variable and changes from month to month are immediately visible.
An individual specialist's query rate primarily measures productivity or workflow rather than overall organizational impact. A pie graph of unanswered queries provides a snapshot of one process metric, not longitudinal program effectiveness. A presentation of program goals and objectives communicates strategy but does not demonstrate measurable results.
ROM and SOI also connect CDI work to quality and risk-adjustment outcomes, making them particularly meaningful to senior hospital administration.
CCDS Reference Topics: Healthcare facility CDI program analysis; trend analysis; SOI/ROM; physician and hospital performance.
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NEW QUESTION # 78
A patient with active breast cancer is admitted solely to receive a scheduled cycle of antineoplastic chemotherapy. No complication or acute disease process is responsible for the admission. Which diagnosis is generally sequenced first?
Answer: D
Explanation:
When an inpatient encounter is solely for administration of chemotherapy, the encounter-for-chemotherapy code is generally sequenced first, followed by the code identifying the malignancy being treated.
This represents an important exception to the usual expectation that the underlying disease is the principal diagnosis. The circumstances of admission are specifically treatment administration rather than management of an acute complication of the malignancy.
If, however, the patient were admitted because of a complication-such as chemotherapy-induced neutropenic fever, dehydration, anemia, or another adverse effect-the principal-diagnosis analysis would follow the applicable guideline for that condition rather than automatically using the chemotherapy encounter code.
Similarly, if chemotherapy were administered incidentally during a hospitalization principally required for another condition, the encounter-for-chemotherapy code would not displace the actual principal diagnosis.
CDI professionals should therefore distinguish planned treatment encounters from admissions caused by complications of treatment or malignancy.
Clear documentation regarding the reason for admission, cancer site, treatment intent, metastatic disease, and complications helps support proper sequencing and accurate oncology data.
CCDS Reference Topics: Antineoplastic chemotherapy; encounter codes; neoplasm sequencing; principal diagnosis; oncology documentation.
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NEW QUESTION # 79
A patient is admitted with alcohol intoxication. The H & P notes increased tolerance related to alcohol consumption, desire to drink despite impaired liver functions, and unsuccessful attempts to stop drinking.
Identify the query opportunity related to alcohol consumption.
Answer: B
Explanation:
The documented behavioral characteristics most strongly support clarification of alcohol dependence. The record describes increased tolerance, continued alcohol use despite recognized medical harm, and unsuccessful efforts to stop drinking. These features reflect a persistent maladaptive pattern with physiologic and behavioral characteristics associated with dependence/alcohol use disorder.
Alcohol intoxication identifies the acute effect of recent consumption but does not describe the patient's underlying pattern of alcohol use. Therefore, the CDI opportunity is to clarify whether a chronic alcohol- related disorder such as dependence is present when clinically supported.
Withdrawal is not established merely because a dependent patient is hospitalized. Withdrawal requires symptoms occurring after reduction or cessation of alcohol exposure, potentially including tremor, autonomic hyperactivity, nausea, anxiety, seizures, hallucinations, or agitation. Delirium tremens represents a severe alcohol-withdrawal syndrome involving delirium and marked autonomic disturbance and is not supported by the scenario.
"Abuse" is less consistent with the pronounced dependence-type behaviors provided. The CDI specialist should nevertheless frame the query neutrally and allow the physician to identify dependence, abuse, another alcohol-related condition, or inability to determine.
CCDS Reference Topics: Substance-related disorders; alcohol dependence; intoxication versus withdrawal; clinical indicators.
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NEW QUESTION # 80
A patient who underwent abdominal surgery one week ago is readmitted specifically for treatment of a postoperative wound infection documented by the surgeon as a complication of the procedure. Which condition should generally be considered for principal diagnosis selection?
Answer: D
Explanation:
When a patient is admitted specifically for treatment of a documented postoperative complication, the complication is generally sequenced as the principal diagnosis when it is established after study to be chiefly responsible for the admission.
In this scenario, the surgeon has explicitly documented the wound infection as a complication of the prior procedure, and treatment of that complication is the reason for the current hospitalization. The original surgical disease therefore does not automatically remain the principal diagnosis simply because it led to the earlier operation.
Fever and abdominal pain are clinical manifestations or symptoms and ordinarily are not sequenced ahead of the definitive postoperative infection once that condition has been established.
A critical CDI principle is that a temporal relationship alone is insufficient to classify a postoperative condition as a complication. The provider must establish the appropriate relationship when required by ICD-
10-CM. Here, that documentation is already present, so a query simply asking whether the infection is postoperative would be unnecessary.
The principal-diagnosis decision should still account for all applicable complication-code sequencing instructions and circumstances of admission. The FY 2026 Official Guidelines emphasize both principal- diagnosis rules and requirements surrounding complications of care.
CCDS Reference Topics: Principal diagnosis; postoperative complications; complications of care; sequencing.
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NEW QUESTION # 81
Which of the following diagnoses is classified as a major complication/comorbidity (MCC) under the FY
2026 MS-DRG system?
Answer: B
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 # 82
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