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| Section | Weight | Objectives |
|---|---|---|
| Impact of reportable diagnoses on quality of care | 8.33% | - Mortality reviews and observed/expected ratios - Hospital-Acquired Condition Reduction Program - CDI impact on Hospital Value-Based Purchasing - Healthcare-associated infections and complication codes - Documentation and code assignment impact on mortality index - Hospital Readmissions Reduction Program - Hospital Inpatient Quality Reporting Program - Coded data elements affecting Patient Safety Indicators - Quality data from record abstraction and claims data - 30-day mortality measures - Hospital Value-Based Purchasing - Patient Safety Indicators |
| Healthcare regulations, reimbursement, and documentation requirements related to the IPPS | 12.5% | - Medicare Severity Diagnosis Related Groups (MS-DRGs) - Principal diagnosis and medical necessity - Coding and billing practices vulnerable to denial - Case mix index (CMI) - Medicare contractors and their impact on CDI - Major complication/comorbidity (MCC) - Complication/comorbidity (CC) - Inpatient admission criteria and CMS Two-Midnight Rule - Medical staff and clinical staff documentation responsibilities - Documentation and medical necessity of setting - Documentation impact on IPPS reimbursement - IPPS and its updates and revisions |
| Medical record documentation | 19.17% | - Physician query formats - Compliant and noncompliant queries - Addressing diagnoses without clinical support - Provider role and diagnosis code assignment - When a physician query is warranted - Types of physician queries - ACDIS/AHIMA Guidelines for Achieving a Compliant Query Practice - Documentation requiring clarification - Clinical indicators - Situations in which queries are not appropriate - Health record elements used for diagnosis and procedure code assignment - Translating clinical indicators into compliant queries |
| Professionalism, ethics, and compliance | 9.17% | - Medical record confidentiality - DRG compliance initiatives - CDI department goals beyond reimbursement - Compliance risks indicated by PEPPER - Leading queries - Potential DRG creep |
| Anatomy and physiology, pathophysiology, pharmacology, and medical terminology | 19.17% | - Diseases and disorders of the circulatory system - Diseases and disorders of the respiratory system - Alcohol/drug use and alcohol/drug-induced organic brain disorders - Diseases and disorders of the skin, subcutaneous tissue, and breast - Endocrine, nutritional, and metabolic diseases and disorders - HIV infections - Diseases and disorders of the hepatobiliary system - Infectious and parasitic diseases - Diagnostic tests as clinical indicators - Mental diseases and disorders - Medications as clinical indicators - Diseases and disorders of the blood and blood-forming organs and immunological disorders - Diseases and disorders of the digestive system - Diseases and disorders of the musculoskeletal system - Standard medical abbreviations - Pharmaceuticals and disease processes - Injuries, poisonings, and toxic effects of drugs - Diseases and disorders of the nervous system - Myeloproliferative diseases and disorders and poorly differentiated neoplasms - Diseases and disorders of the kidney and urinary tract - Clinical indicators and query opportunities by Major Diagnostic Category |
| Official Guidelines for Coding and Reporting | 14.17% | - AHA Coding Clinic - Principal diagnosis assignment - Hospital-acquired conditions - Discharge dispositions and transfers - Coding guidelines for principal diagnosis selection - Present on admission indicators - Secondary diagnosis assignment - Working DRG assignment for multiple diagnoses - Official Guidelines for Coding and Reporting updates |
| Healthcare facility CDI program analysis | 8.33% | - CDI program forecasting - Basic computer and software application skills - Severity of illness and risk of mortality - Publicly reported data - Case mix index (CMI) - High-frequency DRGs - PEPPER data - Provider response rates - Tracking and trending physician, department, and hospital performance - Physician performance measurement - CC/MCC capture - Hospital Value-Based Purchasing measures - Hospital-specific financial data - CDI specialist productivity metrics - Patient Safety Indicators |
| Communication skills | 9.17% | - Roles and responsibilities of CDI specialists - Roles and responsibilities of coders working with CDI departments - Verbal versus written physician communication - Educational presentations for healthcare departments and administration - Physician education forms and tools - Effective and non-confrontational physician communication - Reconciling CDI working DRGs with final coded DRGs |
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NEW QUESTION # 105
An 82-year-old patient with a urinary infection develops an acute fluctuating disturbance in attention, disorganized thinking, and altered level of consciousness. The family states the patient was cognitively normal three days earlier. Which condition is MOST consistent with this presentation?
Answer: D
Explanation:
The presentation is most consistent with delirium, an acute and fluctuating disturbance in attention, awareness, and cognition that frequently develops in medically ill hospitalized patients.
The abrupt onset over several days and fluctuating cognitive state distinguish delirium from most forms of dementia, which generally develop progressively over months or years. Infection, medications, metabolic abnormalities, dehydration, hypoxia, and organ dysfunction are common precipitants.
A urinary infection may be a contributing clinical factor, but CDI should not automatically establish a cause- and-effect relationship between infection and delirium unless supported by provider documentation.
The CDI specialist should also recognize that terms such as "altered mental status" are symptoms rather than equivalent substitutes for a more specific diagnosis. When the clinical record contains sufficient indicators and the provider has documented only nonspecific mental-status terminology, a query may be warranted.
Intellectual disability represents a developmental condition rather than an acute change in cognition. A persistent vegetative state represents profound and persistent impairment of consciousness and is inconsistent with the described fluctuating presentation.
CCDS Reference Topics: Delirium; altered mental status; cognitive disorders; clinical indicators; documentation specificity.
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NEW QUESTION # 106
A patient is admitted with a stage 2 sacral pressure ulcer. During the hospitalization, the ulcer progresses and is documented as stage 3 at the same site. How should the pressure ulcer be reported?
Answer: A
Explanation:
The FY 2026 ICD-10-CM Official Guidelines specifically address a pressure ulcer that progresses to a higher stage during an inpatient admission. Two codes are assigned: one representing the site and stage present on admission and another representing the same ulcer site at the highest stage documented during the hospitalization.
Therefore, this patient's stage 2 sacral pressure ulcer on admission and subsequent progression to stage 3 must both be represented according to the applicable coding instructions.
The distinction is important for both clinical and quality purposes because the record must accurately show what condition existed when the patient entered the hospital and how the wound subsequently evolved.
Coding only the stage 3 ulcer would lose information about its status at admission. Coding only stage 2 would fail to represent the deterioration that occurred during the stay.
Pressure-ulcer staging is also one of the circumstances in which qualified non-provider clinician documentation, such as wound-care nursing documentation, may be used to establish stage when the diagnosis itself is appropriately documented.
For CDI, accurate wound location, stage, progression, and POA documentation are essential because advanced pressure injuries may influence MS-DRG severity and hospital quality reporting.
CCDS Reference Topics: Pressure ulcers; staging; POA; wound-care documentation; Official Guidelines.
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NEW QUESTION # 107
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 # 108
A patient is admitted with shortness of breath and dyspnea. Physical examination documents percussion dullness of the chest and decreased breath sounds. A chest x-ray indicates an increase in fluid with complete opacification of the hemithorax and mediastinal shift to the contralateral side. Which of the following conditions should be queried with the physician?
Answer: D
Explanation:
The findings are characteristic of a large or massive pleural effusion. Pleural fluid produces dullness to percussion and diminished breath sounds because fluid within the pleural space reduces normal transmission of respiratory sounds and replaces the normally air-filled acoustic environment.
A sufficiently large effusion can cause complete or near-complete opacification of a hemithorax on chest radiography. Importantly, a large-volume effusion exerts mass effect and can push the mediastinum away from the affected side, producing contralateral mediastinal shift. That combination strongly supports pleural effusion as the appropriate diagnostic clarification.
Pneumonia can produce focal opacity and abnormal breath sounds, but extensive consolidation often causes air bronchograms and typically does not create the same fluid-related contralateral mass effect. Atelectasis can opacify a hemithorax but usually pulls the mediastinum toward the affected side because of volume loss.
Bronchiectasis has different radiographic characteristics, including chronic bronchial dilation. Heart failure may cause pleural effusions but does not itself describe the immediate radiographic abnormality being presented.
A CDI query should seek provider confirmation rather than independently diagnose the effusion.
CCDS Reference Topics: Pleural disease; chest radiographic interpretation; pulmonary clinical indicators; diagnostic clarification.
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NEW QUESTION # 109
A CDI specialist's working MS-DRG differs from the final coder-assigned MS-DRG in 18% of reviewed cases. What is the BEST initial management response?
Answer: A
Explanation:
A significant mismatch rate should trigger structured CDI/coding reconciliation, not an assumption that either department is wrong.
Working MS-DRGs are provisional. Final coding may change because of discharge-summary diagnoses, operative reports, pathology results, late physician clarification, Coding Clinic guidance, sequencing conventions, final procedure coding, CC/MCC exclusions, or other grouper logic unavailable during the concurrent CDI review.
The manager should categorize mismatch causes. Useful categories include principal-diagnosis differences, missed secondary diagnoses, procedure-code differences, coding-guideline interpretation, query results, discharge documentation, and technical grouper issues.
Patterns can then identify whether education is needed for CDI specialists, coding professionals, physicians, or multiple groups.
Requiring coding staff to adopt the CDI working DRG would undermine coding independence and final coding accountability. Excluding mismatches from metrics would conceal an important quality indicator.
CMS confirms that the FY 2026 MS-DRG Definitions Manual contains the complete grouper logic for Version 43.1, making current grouper rules essential when evaluating discrepancies.
CCDS Reference Topics: MS-DRG reconciliation; CDI/coder agreement; program analysis; education; grouper logic.
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NEW QUESTION # 110
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