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| Section | Weight | Objectives |
|---|---|---|
| Topic 1: Professionalism, ethics, and compliance | 9.17% | - DRG compliance initiatives - Compliance risks indicated by PEPPER - Medical record confidentiality - Potential DRG creep - CDI department goals beyond reimbursement - Leading queries |
| Topic 2: Medical record documentation | 19.17% | - Situations in which queries are not appropriate - Documentation requiring clarification - Physician query formats - Provider role and diagnosis code assignment - Compliant and noncompliant queries - Translating clinical indicators into compliant queries - Types of physician queries - Health record elements used for diagnosis and procedure code assignment - When a physician query is warranted - Clinical indicators - Addressing diagnoses without clinical support - ACDIS/AHIMA Guidelines for Achieving a Compliant Query Practice |
| Topic 3: Official Guidelines for Coding and Reporting | 14.17% | - Official Guidelines for Coding and Reporting updates - Principal diagnosis assignment - Hospital-acquired conditions - Present on admission indicators - Coding guidelines for principal diagnosis selection - Secondary diagnosis assignment - AHA Coding Clinic - Working DRG assignment for multiple diagnoses - Discharge dispositions and transfers |
| Topic 4: Impact of reportable diagnoses on quality of care | 8.33% | - Coded data elements affecting Patient Safety Indicators - Hospital Readmissions Reduction Program - Documentation and code assignment impact on mortality index - Healthcare-associated infections and complication codes - Patient Safety Indicators - 30-day mortality measures - Hospital Value-Based Purchasing - Hospital-Acquired Condition Reduction Program - CDI impact on Hospital Value-Based Purchasing - Hospital Inpatient Quality Reporting Program - Quality data from record abstraction and claims data - Mortality reviews and observed/expected ratios |
| Topic 5: Healthcare facility CDI program analysis | 8.33% | - Publicly reported data - Physician performance measurement - Case mix index (CMI) - Patient Safety Indicators - PEPPER data - Hospital-specific financial data - Basic computer and software application skills - CDI specialist productivity metrics - Hospital Value-Based Purchasing measures - High-frequency DRGs - Tracking and trending physician, department, and hospital performance - Provider response rates - CC/MCC capture - Severity of illness and risk of mortality - CDI program forecasting |
| Topic 6: Anatomy and physiology, pathophysiology, pharmacology, and medical terminology | 19.17% | - Endocrine, nutritional, and metabolic diseases and disorders - Standard medical abbreviations - Mental diseases and disorders - Pharmaceuticals and disease processes - Diseases and disorders of the kidney and urinary tract - Clinical indicators and query opportunities by Major Diagnostic Category - Injuries, poisonings, and toxic effects of drugs - Diseases and disorders of the blood and blood-forming organs and immunological disorders - Diseases and disorders of the nervous system - HIV infections - Diseases and disorders of the hepatobiliary system - Diseases and disorders of the respiratory system - Infectious and parasitic diseases - Alcohol/drug use and alcohol/drug-induced organic brain disorders - Diagnostic tests as clinical indicators - Diseases and disorders of the skin, subcutaneous tissue, and breast - Diseases and disorders of the circulatory system - Medications as clinical indicators - Diseases and disorders of the musculoskeletal system - Diseases and disorders of the digestive system - Myeloproliferative diseases and disorders and poorly differentiated neoplasms |
| Topic 7: Communication skills | 9.17% | - Educational presentations for healthcare departments and administration - Effective and non-confrontational physician communication - Physician education forms and tools - Roles and responsibilities of CDI specialists - Verbal versus written physician communication - Reconciling CDI working DRGs with final coded DRGs - Roles and responsibilities of coders working with CDI departments |
| Topic 8: Healthcare regulations, reimbursement, and documentation requirements related to the IPPS | 12.5% | - Documentation and medical necessity of setting - Complication/comorbidity (CC) - Case mix index (CMI) - Medicare contractors and their impact on CDI - Inpatient admission criteria and CMS Two-Midnight Rule - Coding and billing practices vulnerable to denial - Medical staff and clinical staff documentation responsibilities - Major complication/comorbidity (MCC) - Medicare Severity Diagnosis Related Groups (MS-DRGs) - IPPS and its updates and revisions - Documentation impact on IPPS reimbursement - Principal diagnosis and medical necessity |
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NEW QUESTION # 21
A patient develops chest pain and elevated troponins while receiving care in the emergency department. The physician diagnoses an NSTEMI. Several hours later, an inpatient admission order is written. How should the NSTEMI generally be considered for POA purposes?
Answer: B
Explanation:
For POA reporting, "present on admission" refers to a condition present at the time the order for inpatient admission occurs. Conditions that develop during an outpatient encounter-including emergency-department, observation, or outpatient surgery care-before the inpatient admission order are generally considered POA when they are present at that inpatient admission point.
Therefore, the NSTEMI in this scenario is considered present on admission even though it developed after the patient physically arrived at the hospital.
This distinction is essential because hospital arrival and inpatient admission are not synonymous for POA purposes. A patient may spend hours in the ED or observation status before an inpatient order is entered.
The POA indicator applies to applicable principal and secondary diagnoses and is important to CMS's HAC payment provisions as well as quality analysis. A condition does not become hospital acquired merely because it arose somewhere on hospital premises before inpatient status began.
CDI specialists should clarify timing when the record does not establish whether a diagnosis existed before or after the inpatient admission order rather than relying solely on note timestamps or physical location.
The FY 2026 ICD-10-CM Official Guidelines contain the governing POA definitions and reporting rules.
CCDS Reference Topics: POA; emergency department; observation; timing of diagnosis; HAC payment logic.
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NEW QUESTION # 22
A patient is admitted with community-acquired pneumonia. On day 3, he begins to show signs of increasing respiratory distress and requires intubation. When he arrives in the ICU, the nurse inserts a urinary catheter and notes that his urine output has decreased. The physician documents respiratory failure and acute renal failure secondary to sepsis caused by pneumonia. The patient's condition would be classified as:
Answer: B
Explanation:
This patient has sepsis with documented acute organ dysfunction, specifically acute respiratory failure and acute renal failure. Under ICD-10-CM coding guidance, sepsis associated with acute organ dysfunction is classified as severe sepsis when the provider establishes the relationship between the systemic infection and the organ dysfunction.
The documentation specifically states that respiratory failure and acute renal failure are secondary to sepsis caused by pneumonia. That causal linkage is critical. FY 2026 Official Guidelines require the underlying systemic infection code, followed by a code from R65.2- for severe sepsis, plus additional codes identifying each associated acute organ dysfunction.
Septic shock is not supported because the scenario does not document circulatory failure attributable to sepsis, persistent hypotension requiring vasopressors, or a provider diagnosis of septic shock. "Septicemia" is also not equivalent terminology for coding sepsis and is not the appropriate classification here.
From a CDI perspective, the defining feature is not simply that the patient is critically ill. It is the documented relationship between sepsis and acute organ dysfunction.
CCDS Reference Topics: Sepsis; severe sepsis; acute organ dysfunction; sequencing guidelines.
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NEW QUESTION # 23
Which of the following diagnoses is classified as a major complication/comorbidity (MCC) under the FY
2026 MS-DRG system?
Answer: A
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 # 24
A patient is admitted with a stage 4 pressure ulcer of the right heel. The physician documents the pressure- ulcer diagnosis and location. The wound-care nurse documents stage 4. Which statement is MOST accurate?
Answer: C
Explanation:
Pressure-ulcer staging is one of the recognized circumstances in which ICD-10-CM permits the relevant clinical detail to be obtained from documentation by an appropriate non-provider clinician, such as a qualified wound-care nurse.
The provider establishes the medical diagnosis, while the wound-care clinician's specialized assessment may support the stage assignment. This distinction allows coding to reflect the expertise of clinicians who directly assess the wound without requiring physicians to duplicate every technical staging statement.
Option C is too broad. The exception permitting stage documentation from another clinician does not grant non-provider documentation unrestricted authority to establish all reportable medical diagnoses.
Pressure-ulcer stage is highly relevant because ICD-10-CM pressure-ulcer codes incorporate both anatomical site and stage. It can also have substantial implications for severity reporting, POA assessment, CMS HAC policy, nursing care, quality review, and risk adjustment.
When different clinicians document conflicting stages, clarification should be pursued rather than selecting the most severe value.
CCDS candidates should understand the distinction between provider-established diagnoses and specific coding elements that ICD-10-CM permits to originate from other qualified professionals.
CCDS Reference Topics: Pressure ulcers; wound staging; non-provider documentation; coding exceptions.
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NEW QUESTION # 25
A patient with COPD normally has a PaCO# of approximately 45 mmHg. The patient is admitted with increasing somnolence and respiratory distress. Arterial blood gas results are pH 7.27, PaCO# 68 mmHg, and PaO# 58 mmHg. BiPAP is initiated. Which condition is MOST appropriate for the CDI specialist to consider as a clarification opportunity?
Answer: B
Explanation:
The findings strongly support a clarification opportunity for acute hypercapnic respiratory failure. The patient has a substantial acute rise in PaCO# above the documented baseline, respiratory acidemia with a pH of 7.27, hypoxemia, altered mental status, respiratory distress, and escalation to noninvasive ventilatory support.
In chronic CO# retention, renal compensation commonly increases serum bicarbonate and may allow a relatively preserved pH. A pronounced fall in pH in conjunction with a significant increase in PaCO# suggests an acute ventilatory deterioration. The need for BiPAP provides additional evidence of clinically significant respiratory compromise.
Option C is incorrect because the acidemia is driven primarily by elevated carbon dioxide, indicating respiratory rather than metabolic acidosis. Option A fails to capture the apparent acute deterioration from the patient's baseline. Option D is inconsistent with the physiologic abnormalities and treatment intensity.
The CDI specialist must still obtain provider documentation rather than independently diagnose respiratory failure. The CCDS examination specifically includes acute/chronic respiratory failure, COPD, ventilation support, and diagnostic-test interpretation among expected clinical competencies.
CCDS Reference Topics: Acute respiratory failure; hypercapnia; ABG interpretation; COPD; noninvasive ventilation.
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NEW QUESTION # 26
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