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| Section | Weight | Objectives |
|---|---|---|
| Topic 1: Medical record documentation | 19.17% | - Physician query formats - When a physician query is warranted - Health record elements used for diagnosis and procedure code assignment - Clinical indicators - Types of physician queries - Documentation requiring clarification - ACDIS/AHIMA Guidelines for Achieving a Compliant Query Practice - Addressing diagnoses without clinical support - Compliant and noncompliant queries - Situations in which queries are not appropriate - Translating clinical indicators into compliant queries - Provider role and diagnosis code assignment |
| Topic 2: Official Guidelines for Coding and Reporting | 14.17% | - Hospital-acquired conditions - Discharge dispositions and transfers - AHA Coding Clinic - Principal diagnosis assignment - Official Guidelines for Coding and Reporting updates - Working DRG assignment for multiple diagnoses - Coding guidelines for principal diagnosis selection - Present on admission indicators - Secondary diagnosis assignment |
| Topic 3: Communication skills | 9.17% | - Effective and non-confrontational physician communication - Educational presentations for healthcare departments and administration - Roles and responsibilities of CDI specialists - Roles and responsibilities of coders working with CDI departments - Reconciling CDI working DRGs with final coded DRGs - Physician education forms and tools - Verbal versus written physician communication |
| Topic 4: Professionalism, ethics, and compliance | 9.17% | - Potential DRG creep - Compliance risks indicated by PEPPER - DRG compliance initiatives - CDI department goals beyond reimbursement - Medical record confidentiality - Leading queries |
| Topic 5: Impact of reportable diagnoses on quality of care | 8.33% | - Hospital Readmissions Reduction Program - Quality data from record abstraction and claims data - Mortality reviews and observed/expected ratios - Hospital Inpatient Quality Reporting Program - Healthcare-associated infections and complication codes - CDI impact on Hospital Value-Based Purchasing - Hospital-Acquired Condition Reduction Program - Patient Safety Indicators - 30-day mortality measures - Documentation and code assignment impact on mortality index - Hospital Value-Based Purchasing - Coded data elements affecting Patient Safety Indicators |
| Topic 6: Healthcare regulations, reimbursement, and documentation requirements related to the IPPS | 12.5% | - Medicare Severity Diagnosis Related Groups (MS-DRGs) - Inpatient admission criteria and CMS Two-Midnight Rule - Coding and billing practices vulnerable to denial - Medical staff and clinical staff documentation responsibilities - IPPS and its updates and revisions - Documentation impact on IPPS reimbursement - Medicare contractors and their impact on CDI - Case mix index (CMI) - Complication/comorbidity (CC) - Principal diagnosis and medical necessity - Documentation and medical necessity of setting - Major complication/comorbidity (MCC) |
| Topic 7: Healthcare facility CDI program analysis | 8.33% | - High-frequency DRGs - PEPPER data - Publicly reported data - Hospital Value-Based Purchasing measures - Severity of illness and risk of mortality - Hospital-specific financial data - Tracking and trending physician, department, and hospital performance - Patient Safety Indicators - Basic computer and software application skills - CDI specialist productivity metrics - CC/MCC capture - Physician performance measurement - CDI program forecasting - Case mix index (CMI) - Provider response rates |
| Topic 8: Anatomy and physiology, pathophysiology, pharmacology, and medical terminology | 19.17% | - Standard medical abbreviations - Diseases and disorders of the musculoskeletal system - Diseases and disorders of the kidney and urinary tract - Medications as clinical indicators - Pharmaceuticals and disease processes - Alcohol/drug use and alcohol/drug-induced organic brain disorders - Diseases and disorders of the digestive system - Mental diseases and disorders - Endocrine, nutritional, and metabolic diseases and disorders - Diseases and disorders of the respiratory system - Infectious and parasitic diseases - HIV infections - Diseases and disorders of the circulatory system - Diseases and disorders of the blood and blood-forming organs and immunological disorders - Diseases and disorders of the nervous system - Clinical indicators and query opportunities by Major Diagnostic Category - Diseases and disorders of the hepatobiliary system - Myeloproliferative diseases and disorders and poorly differentiated neoplasms - Diagnostic tests as clinical indicators - Diseases and disorders of the skin, subcutaneous tissue, and breast - Injuries, poisonings, and toxic effects of drugs |
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NEW QUESTION # 81
A physician documents acute kidney injury. The patient's creatinine is 0.8 mg/dL on admission, 0.9 mg/dL the following day, and 0.8 mg/dL at discharge. Urine output remains normal and no renal treatment is provided.
What is the BEST CDI action?
Answer: C
Explanation:
A clinical validation query is appropriate because the documented diagnosis appears inconsistent with the available clinical evidence. The creatinine values remain essentially unchanged, urine output is normal, and there is no apparent treatment or monitoring consistent with acute renal dysfunction.
The CDI specialist cannot simply delete the diagnosis because providers are responsible for establishing diagnoses. Conversely, a diagnosis should not automatically be accepted when substantial clinical evidence raises a legitimate question about its validity.
A compliant query would present the documented AKI together with the pertinent renal findings and request clarification. The provider could confirm AKI and provide supporting clinical reasoning, revise the diagnosis, state that it was ruled out, or document another condition.
Assigning chronic kidney disease would be equally inappropriate because CKD requires evidence of chronic kidney abnormality and cannot be inferred from these laboratory values.
The August 2026 ACDIS/AHIMA query guidance supersedes prior versions and remains the foundational standard for clinical validation and documentation clarification.
Clinical validation protects data integrity because diagnoses influence reimbursement, quality reporting, severity measurement, utilization analysis, and downstream patient information.
CCDS Reference Topics: Clinical validation; AKI; unsupported diagnoses; provider clarification; compliance.
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NEW QUESTION # 82
A hospital has a total MS-DRG relative weight of 2,640 for 1,600 inpatient discharges. What is its case mix index?
Answer: C
Explanation:
Case mix index is calculated by dividing the sum of MS-DRG relative weights by the number of inpatient discharges:
2,640 รท 1,600 = 1.65
Therefore, the CMI is 1.65.
CMI represents the average relative resource intensity of the hospital's inpatient cases. It is affected by the types of patients treated, surgical versus medical mix, tertiary services, transplant or trauma volume, documentation specificity, coding accuracy, and annual changes to MS-DRG relative weights and grouper logic.
CMS publishes hospital case-mix information and FY 2026 relative weighting factors through the IPPS Final Rule supporting data. Table 5 contains MS-DRGs and relative weighting factors, while Table 2 contains hospital-specific case-mix information.
A decline in CMI should not automatically be interpreted as a CDI failure. A shift toward lower-complexity cases or changes in service lines can legitimately reduce CMI even with excellent documentation.
CDI managers should therefore trend CMI alongside diagnosis capture, surgical volume, service lines, payer population, coding reconciliation, and quality indicators.
CCDS Reference Topics: Case mix index; MS-DRG relative weight; CDI analytics; hospital performance.
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NEW QUESTION # 83
Documentation indicates an excisional debridement was performed without further specification. The CDI specialist should query to clarify which of the following?
Answer: B
Explanation:
The most critical missing element is the depth or level of tissue actually debrided. Documentation of an excisional debridement should identify whether tissue removed included skin, subcutaneous tissue, fascia, muscle, bone, or another anatomical layer. The level removed is fundamental to accurate procedural classification and coding.
CMS wound-care documentation standards similarly emphasize that the medical record should describe the type and depth of tissue removed. Merely knowing that an excisional debridement occurred does not establish the anatomical level of the procedure.
The instrument may provide useful procedural context-for example, scalpel, scissors, curette, or other technique-but the instrument alone does not identify the deepest tissue excised. Wound size can be important for clinical care and certain coding systems, but it does not replace documentation of the tissue level removed. The identity of the person performing the procedure is also part of procedural documentation but does not answer the principal coding-specific deficiency in this scenario.
A CDI query should therefore seek the deepest tissue level actually excised rather than infer it from the wound's overall depth.
CCDS Reference Topics: Medical record documentation; ICD-10-PCS/procedure documentation; debridement specificity.
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NEW QUESTION # 84
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: A
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 # 85
A patient undergoes abdominal surgery. Two days later, the physician documents "postoperative anemia." The hemoglobin decreased from 12.4 g/dL preoperatively to 8.2 g/dL, but the record does not state whether the anemia represents an expected postoperative condition, acute blood loss anemia, or a complication of surgery. What should the CDI specialist do?
Answer: C
Explanation:
The appropriate action is to query for clarification. A temporal relationship-anemia occurring after surgery- does not automatically establish that a reportable complication occurred. Likewise, a CDI specialist cannot independently translate a substantial hemoglobin decline into acute posthemorrhagic anemia without provider documentation.
The FY 2026 Official Guidelines state that complication-of-care code assignment depends on provider documentation establishing the relationship between the condition and the care or procedure unless the classification specifically instructs otherwise. They also emphasize that not every condition occurring during or following medical care is a complication.
The query could present the preoperative and postoperative hemoglobin values, estimated blood loss, transfusions, clinical monitoring, and treatment. Appropriate response options might include acute blood loss anemia, expected postoperative anemia, another diagnosis, or clinically unable to determine, depending on the record.
Option A overstates causation. Option B independently diagnoses the patient from laboratory findings. Option D is equally inappropriate because clinically significant postoperative anemia may be reportable.
CCDS Reference Topics: Complications of care; postoperative anemia; clinical indicators; cause-and-effect clarification; compliant querying.
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NEW QUESTION # 86
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