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| Section | Weight | Objectives |
|---|---|---|
| Topic 1: Communication skills | 9.17% | - Educational presentations for healthcare departments and administration - Roles and responsibilities of coders working with CDI departments - Verbal versus written physician communication - Roles and responsibilities of CDI specialists - Reconciling CDI working DRGs with final coded DRGs - Physician education forms and tools - Effective and non-confrontational physician communication |
| Topic 2: Official Guidelines for Coding and Reporting | 14.17% | - Secondary diagnosis assignment - Coding guidelines for principal diagnosis selection - Principal diagnosis assignment - AHA Coding Clinic - Discharge dispositions and transfers - Official Guidelines for Coding and Reporting updates - Working DRG assignment for multiple diagnoses - Hospital-acquired conditions - Present on admission indicators |
| Topic 3: Healthcare facility CDI program analysis | 8.33% | - Tracking and trending physician, department, and hospital performance - Patient Safety Indicators - Hospital-specific financial data - Severity of illness and risk of mortality - Hospital Value-Based Purchasing measures - Publicly reported data - Physician performance measurement - Provider response rates - PEPPER data - Case mix index (CMI) - CDI program forecasting - CDI specialist productivity metrics - Basic computer and software application skills - CC/MCC capture - High-frequency DRGs |
| Topic 4: Professionalism, ethics, and compliance | 9.17% | - Leading queries - Medical record confidentiality - DRG compliance initiatives - CDI department goals beyond reimbursement - Compliance risks indicated by PEPPER - Potential DRG creep |
| Topic 5: Medical record documentation | 19.17% | - Translating clinical indicators into compliant queries - Documentation requiring clarification - Addressing diagnoses without clinical support - When a physician query is warranted - Clinical indicators - ACDIS/AHIMA Guidelines for Achieving a Compliant Query Practice - Health record elements used for diagnosis and procedure code assignment - Compliant and noncompliant queries - Physician query formats - Situations in which queries are not appropriate - Provider role and diagnosis code assignment - Types of physician queries |
| Topic 6: Anatomy and physiology, pathophysiology, pharmacology, and medical terminology | 19.17% | - Medications as clinical indicators - Diseases and disorders of the musculoskeletal system - Standard medical abbreviations - Pharmaceuticals and disease processes - Diseases and disorders of the digestive system - Clinical indicators and query opportunities by Major Diagnostic Category - Diseases and disorders of the blood and blood-forming organs and immunological disorders - Diseases and disorders of the hepatobiliary system - Diseases and disorders of the skin, subcutaneous tissue, and breast - Diseases and disorders of the kidney and urinary tract - Diseases and disorders of the nervous system - HIV infections - Diagnostic tests as clinical indicators - Endocrine, nutritional, and metabolic diseases and disorders - Alcohol/drug use and alcohol/drug-induced organic brain disorders - Diseases and disorders of the respiratory system - Injuries, poisonings, and toxic effects of drugs - Infectious and parasitic diseases - Myeloproliferative diseases and disorders and poorly differentiated neoplasms - Mental diseases and disorders - Diseases and disorders of the circulatory system |
| Topic 7: Impact of reportable diagnoses on quality of care | 8.33% | - CDI impact on Hospital Value-Based Purchasing - Healthcare-associated infections and complication codes - Patient Safety Indicators - Hospital Inpatient Quality Reporting Program - Mortality reviews and observed/expected ratios - Coded data elements affecting Patient Safety Indicators - 30-day mortality measures - Quality data from record abstraction and claims data - Hospital-Acquired Condition Reduction Program - Hospital Value-Based Purchasing - Documentation and code assignment impact on mortality index - Hospital Readmissions Reduction Program |
| Topic 8: Healthcare regulations, reimbursement, and documentation requirements related to the IPPS | 12.5% | - Principal diagnosis and medical necessity - Medicare contractors and their impact on CDI - Documentation impact on IPPS reimbursement - Inpatient admission criteria and CMS Two-Midnight Rule - Major complication/comorbidity (MCC) - Case mix index (CMI) - IPPS and its updates and revisions - Medical staff and clinical staff documentation responsibilities - Complication/comorbidity (CC) - Coding and billing practices vulnerable to denial - Documentation and medical necessity of setting - Medicare Severity Diagnosis Related Groups (MS-DRGs) |
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NEW QUESTION # 95
A hospital records 72 observed deaths, while its risk-adjustment model predicts 90 expected deaths. What is the observed-to-expected mortality ratio?
Answer: D
Explanation:
Observed-to-expected mortality is calculated as:
Observed deaths ÷ Expected deaths
Therefore:
72 ÷ 90 = 0.80.
An O/E ratio of 0.80 means that observed mortality was lower than predicted by the applicable risk- adjustment model. Specifically, observed deaths were 20% below the expected number.
A ratio of 1.0 indicates observed mortality equals expected mortality. Values above 1.0 indicate more deaths than predicted, while values below 1.0 indicate fewer deaths than predicted.
CDI influences the integrity of mortality analysis because the documented disease burden contributes to clinical data used by many risk-adjustment methodologies. If significant comorbidities are incompletely documented, expected mortality may not fully reflect the patient's clinical risk.
However, mortality review must never become a mechanism for adding unsupported diagnoses. The objective is accurate clinical representation.
The CCDS candidate handbook explicitly identifies data analysis, reporting functions, medical-record review, and the impact of documentation on clinical and administrative outcomes as important CDI competencies.
CCDS Reference Topics: Mortality index; O/E ratio; risk adjustment; quality reporting; CDI analytics.
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NEW QUESTION # 96
The amount of the IPPS Indirect Medical Education Adjustment is determined by teaching intensity as measured by the hospital's number of residents compared to:
Answer: B
Explanation:
Medicare's Indirect Medical Education (IME) adjustment uses the hospital's resident-to-bed ratio as the principal measure of teaching intensity. CMS explains that the IME adjustment factor is calculated using a hospital's ratio of residents to beds. Therefore, the correct answer is inpatient beds.
IME is an additional IPPS payment intended to recognize the higher indirect patient-care costs associated with operating an approved teaching program. These costs are distinguished from Direct Graduate Medical Education payments, which reimburse qualifying direct costs associated with residency training.
The number of admissions is not the denominator in the IME teaching-intensity calculation. Likewise, emergency-department beds are not simply combined with inpatient beds for the standard resident-to-bed ratio, and disproportionate-share payment rates represent a separate IPPS adjustment related principally to hospitals caring for substantial numbers of low-income patients.
For the CCDS examination, the important distinction is that IPPS reimbursement involves more than the base MS-DRG payment. Adjustments may include IME, disproportionate-share hospital provisions, wage-index effects, outlier payments, and other statutory mechanisms.
CCDS Reference Topics: IPPS reimbursement; teaching hospitals; IME adjustment; resident-to-bed ratio.
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NEW QUESTION # 97
At discharge, the physician documents, "Possible gram-negative pneumonia." No later documentation rules out the condition. How should the diagnosis generally be handled for an inpatient admission?
Answer: C
Explanation:
In the inpatient hospital setting, an uncertain diagnosis documented at discharge using terminology such as possible, probable, suspected, likely, questionable, compatible with, or consistent with may generally be coded as though the condition existed or was established.
Therefore, "possible gram-negative pneumonia" may be coded in accordance with the inpatient uncertain- diagnosis guideline when it remains the final diagnostic conclusion.
The rationale is that inpatient diagnostic evaluation and treatment frequently occur before absolute confirmation is available, and the patient may have been managed as though the suspected disease were present.
This rule is materially different from outpatient coding, where uncertain diagnoses are generally not coded as established and the documented signs, symptoms, or confirmed conditions are reported instead.
The presence of the uncertain terminology alone does not mandate a query. A query would be appropriate if documentation is contradictory, if the diagnosis is clinically unsupported, or if another documentation issue prevents correct code assignment.
CDI specialists need to recognize this inpatient-specific rule because unnecessary queries for "possible" or
"probable" diagnoses can create physician burden without improving coding accuracy.
CCDS Reference Topics: Uncertain inpatient diagnoses; discharge documentation; pneumonia; inpatient versus outpatient coding.
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NEW QUESTION # 98
A neurologist documents acute cerebral infarction. A qualified stroke nurse records the NIH Stroke Scale score in the medical record. Which statement is MOST accurate?
Answer: B
Explanation:
ICD-10-CM permits the NIH Stroke Scale score to be reported from documentation by an appropriate clinician other than the provider responsible for establishing the diagnosis. The underlying stroke diagnosis itself must be appropriately documented by the provider.
This is similar to other specified exceptions such as BMI, pressure-ulcer stage, coma scale values, and certain additional clinical elements for which qualified non-provider documentation may support code assignment.
The exception does not mean that a stroke nurse can independently establish cerebral infarction for coding.
Rather, once the provider has documented the stroke, the nurse's formal NIHSS assessment can supply the standardized severity measurement.
This approach recognizes that specially trained clinical professionals routinely collect and document these structured measurements as part of patient care.
If multiple NIHSS values are documented, the applicable coding instructions and timing requirements should be followed rather than simply selecting the highest score because it produces a different code.
For CDI professionals, awareness of these non-provider documentation exceptions prevents unnecessary physician queries while ensuring that important severity information is not lost.
CCDS Reference Topics: NIH Stroke Scale; cerebral infarction; non-provider documentation; coding exceptions; stroke severity.
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NEW QUESTION # 99
A patient has chronic gastroesophageal reflux disease listed in the past medical history. During the current hospitalization for bacterial pneumonia, GERD receives no clinical evaluation, treatment, diagnostic testing, increased nursing monitoring, or effect on length of stay. Which statement is MOST accurate?
Answer: A
Explanation:
A condition documented in the medical record does not automatically qualify as a reportable secondary diagnosis. For inpatient coding, additional diagnoses generally must be clinically significant during the current hospitalization. Qualifying significance includes clinical evaluation, therapeutic treatment, diagnostic procedures, an extended length of stay, or increased nursing care and/or monitoring.
Here, GERD is merely part of the patient's historical medical background and does not affect current management. Therefore, it generally should not be reported as an additional diagnosis solely because it appears in the past medical history.
Whether a diagnosis is classified as a CC or MCC is a separate issue. A condition must first satisfy applicable reporting requirements before its MS-DRG severity classification matters. CDI specialists should never encourage coding of clinically irrelevant historical conditions merely because they could affect reimbursement.
This principle protects the clinical integrity of coded data and prevents inappropriate inflation of disease burden. CDI review should focus on conditions that meaningfully describe the patient's current hospitalization, treatment requirements, clinical risk, and resource consumption.
CCDS Reference Topics: Reporting additional diagnoses; secondary-diagnosis criteria; medical-record review; resource utilization; coding compliance.
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NEW QUESTION # 100
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