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| Section | Weight | Objectives |
|---|---|---|
| Healthcare facility CDI program analysis | 8.33% | - CC/MCC capture - Physician performance measurement - Severity of illness and risk of mortality - Basic computer and software application skills - Tracking and trending physician, department, and hospital performance - Provider response rates - Patient Safety Indicators - Hospital-specific financial data - CDI program forecasting - Publicly reported data - Case mix index (CMI) - CDI specialist productivity metrics - Hospital Value-Based Purchasing measures - PEPPER data - High-frequency DRGs |
| Official Guidelines for Coding and Reporting | 14.17% | - Working DRG assignment for multiple diagnoses - Official Guidelines for Coding and Reporting updates - Coding guidelines for principal diagnosis selection - Present on admission indicators - Principal diagnosis assignment - Hospital-acquired conditions - Secondary diagnosis assignment - Discharge dispositions and transfers - AHA Coding Clinic |
| Professionalism, ethics, and compliance | 9.17% | - Compliance risks indicated by PEPPER - Medical record confidentiality - CDI department goals beyond reimbursement - DRG compliance initiatives - Potential DRG creep - Leading queries |
| Impact of reportable diagnoses on quality of care | 8.33% | - Coded data elements affecting Patient Safety Indicators - Hospital Readmissions Reduction Program - Hospital Value-Based Purchasing - Hospital-Acquired Condition Reduction Program - CDI impact on Hospital Value-Based Purchasing - Hospital Inpatient Quality Reporting Program - Documentation and code assignment impact on mortality index - Quality data from record abstraction and claims data - Patient Safety Indicators - 30-day mortality measures - Mortality reviews and observed/expected ratios - Healthcare-associated infections and complication codes |
| Anatomy and physiology, pathophysiology, pharmacology, and medical terminology | 19.17% | - Diseases and disorders of the respiratory system - Diseases and disorders of the circulatory system - Diseases and disorders of the digestive system - Diseases and disorders of the musculoskeletal system - Myeloproliferative diseases and disorders and poorly differentiated neoplasms - Injuries, poisonings, and toxic effects of drugs - 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 nervous system - Diseases and disorders of the skin, subcutaneous tissue, and breast - Diagnostic tests as clinical indicators - Medications as clinical indicators - Pharmaceuticals and disease processes - HIV infections - Standard medical abbreviations - Endocrine, nutritional, and metabolic diseases and disorders - Diseases and disorders of the kidney and urinary tract - Mental diseases and disorders - Alcohol/drug use and alcohol/drug-induced organic brain disorders - Diseases and disorders of the hepatobiliary system - Infectious and parasitic diseases |
| Medical record documentation | 19.17% | - Health record elements used for diagnosis and procedure code assignment - Provider role and diagnosis code assignment - Situations in which queries are not appropriate - Documentation requiring clarification - ACDIS/AHIMA Guidelines for Achieving a Compliant Query Practice - Types of physician queries - When a physician query is warranted - Addressing diagnoses without clinical support - Compliant and noncompliant queries - Translating clinical indicators into compliant queries - Physician query formats - Clinical indicators |
| Communication skills | 9.17% | - Roles and responsibilities of CDI specialists - Verbal versus written physician communication - Effective and non-confrontational physician communication - Roles and responsibilities of coders working with CDI departments - Educational presentations for healthcare departments and administration - Physician education forms and tools - Reconciling CDI working DRGs with final coded DRGs |
| Healthcare regulations, reimbursement, and documentation requirements related to the IPPS | 12.5% | - Coding and billing practices vulnerable to denial - Documentation impact on IPPS reimbursement - Major complication/comorbidity (MCC) - Inpatient admission criteria and CMS Two-Midnight Rule - Principal diagnosis and medical necessity - IPPS and its updates and revisions - Documentation and medical necessity of setting - Case mix index (CMI) - Medicare contractors and their impact on CDI - Medicare Severity Diagnosis Related Groups (MS-DRGs) - Medical staff and clinical staff documentation responsibilities - Complication/comorbidity (CC) |
Success in the ACDIS CCDS certification exam gives a huge boost to your career in the sector. You polish and validate your capabilities with the ACDIS CCDS. However, certification test demands a thorough knowledge of ACDIS CCDS Exam domains from credible preparation material, and this is the part where test takers lose hope.
NEW QUESTION # 142
The PRIMARY goal of a CDI specialist's work is to support complete and specific documentation that results in:
Answer: C
Explanation:
The fundamental objective of clinical documentation integrity is to ensure that the health record accurately represents the patient's clinical condition, including severity of illness, complexity, acuity, diagnoses, treatments, and outcomes. Reimbursement is an important downstream consequence of documentation and coding, but maximizing reimbursement is not the primary professional objective of CDI.
The ACDIS CCDS framework describes the CDI specialist as applying clinical knowledge to determine how documentation translates into coded data and educating providers so the record appropriately reflects severity, complexity, and acuity. This distinction is critical from an ethics and compliance perspective. A CDI program must pursue documentation accuracy whether clarification raises, lowers, or leaves reimbursement unchanged.
Reducing HACs is principally a clinical-quality and patient-safety function. CDI can improve the accuracy with which HACs are identified and reported, but it does not directly prevent those conditions. Similarly, improved provider communication is an important mechanism used by CDI professionals, but it is a means toward accurate documentation rather than the primary endpoint.
Therefore, A most accurately captures the broad clinical, coding, quality, and compliance purpose of CDI.
CCDS Reference Topics: Professionalism, ethics, and compliance; Medical record documentation; goals of CDI beyond reimbursement.
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NEW QUESTION # 143
A patient is admitted with fever and weakness. On hospital day 3, final blood cultures identify an infection that the physician documents was present at the time of admission. Which statement about present-on- admission status is MOST accurate?
Answer: C
Explanation:
A condition can be assigned present-on-admission status even when the definitive diagnosis is not made until later in the hospitalization. POA refers to whether the condition was present at the time the order for inpatient admission occurred, not the calendar date on which diagnostic confirmation became available.
This distinction is particularly relevant for infections, malignancies, fractures, acute vascular events, and other conditions whose definitive identification may require cultures, pathology, imaging, or additional diagnostic testing.
Therefore, a blood culture finalized on hospital day 3 does not automatically make the infection hospital acquired. The clinical record and provider documentation must establish whether the disease process was present at admission.
POA assignment applies to applicable principal and secondary diagnoses, not only the principal diagnosis.
CDI specialists should recognize unclear timing as a potential clarification opportunity because POA status can affect CMS Hospital-Acquired Condition payment logic and quality reporting.
The CCDS content outline expressly includes the basics of POA assignment and its impact on payment, as well as identification of CMS HACs.
CCDS Reference Topics: Present on admission; diagnosis timing; HACs; inpatient coding; quality reporting.
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NEW QUESTION # 144
A patient with severe cachexia and substantial loss of appetite requires pharmacologic treatment to stimulate appetite. Which of the following medications is most commonly associated with this indication?
Answer: B
Explanation:
Megestrol acetate is the correct choice. This item is adapted from an official ACDIS CCDS sample question in the Candidate Handbook, where Megace-megestrol acetate-is identified as the appropriate appetite- stimulating medication.
Megestrol acetate is a synthetic progestational agent with recognized appetite-stimulating effects. Current U.
S. prescribing information specifically identifies megestrol acetate oral suspension for anorexia, cachexia, or significant unexplained weight loss in patients with AIDS. Its use illustrates why CDI specialists need functional knowledge of pharmacology: medication profiles can provide clinically relevant clues to diagnoses under evaluation, although a medication alone never establishes a reportable diagnosis.
Memantine is primarily used in Alzheimer's disease and is not an appetite stimulant. Levothyroxine replaces thyroid hormone in hypothyroidism. Sibutramine was historically used for weight reduction rather than cachexia and is therefore directionally opposite to the desired effect.
In CDI review, identification of megestrol may prompt assessment of the record for malnutrition, cachexia, malignancy-related weight loss, HIV-associated wasting, or another underlying cause, but the provider must document the diagnosis.
CCDS Reference Topics: Pharmacology; cachexia; nutrition disorders; clinical indicators.
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NEW QUESTION # 145
The attending physician documents morbid obesity. A registered dietitian documents a body mass index of
43.6 kg/m² in the nutritional assessment. Which of the following is the MOST accurate statement?
Answer: C
Explanation:
BMI is one of the explicit ICD-10-CM exceptions permitting code assignment from documentation by a clinician other than the provider responsible for establishing the diagnosis. Therefore, the BMI of 43.6 may be taken from the dietitian's documentation, while the associated diagnosis of morbid obesity is supported by the attending physician's documentation.
The FY 2026 Official Guidelines specifically identify BMI, pressure-ulcer stage, non-pressure ulcer depth, coma scale, NIH Stroke Scale, certain social determinants, laterality, blood alcohol level, and several other elements as information that may be documented by other qualified clinicians. However, the associated diagnosis, such as obesity, must be documented by the patient's provider.
Option C incorrectly gives the dietitian's BMI documentation authority to establish the obesity diagnosis itself. Option D imposes an unnecessary discharge-summary requirement; valid diagnoses may be supported by appropriate provider documentation elsewhere in the health record according to applicable coding rules.
For CDI specialists, the key distinction is between a diagnosis and a permissible clinical detail used to further characterize that diagnosis.
CCDS Reference Topics: BMI; non-provider documentation; obesity; medical-record review; coding documentation exceptions.
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NEW QUESTION # 146
A patient's record contains fever, tachycardia, hypotension, positive blood cultures, and treatment with IV antibiotics and fluids. No corresponding diagnosis has been documented. Which query format is MOST appropriate?
Answer: D
Explanation:
A neutral multiple-choice query is appropriate when significant clinical indicators exist but no corresponding diagnosis has been documented. The query should present the relevant patient-specific facts and allow the provider to exercise independent clinical judgment among reasonable alternatives.
For example, depending on the complete record, options could include sepsis, localized infection without sepsis, bacteremia, another condition, or unable to determine. Each offered diagnosis must be clinically supported.
A yes/no query is generally inappropriate when it introduces a completely new diagnosis that has never appeared in the health record. Option B is overtly leading because it directs the provider to document sepsis rather than requesting clarification.
The 2026 ACDIS/AHIMA compliant-query guidance, published August 20, 2026, supersedes all previous versions and serves as the current foundational standard for CDI and coding query practice. It applies across inpatient, outpatient, ambulatory, and professional-fee settings.
The purpose of the query is documentation integrity-not obtaining an MCC, changing the MS-DRG, or achieving a particular quality result.
CCDS Reference Topics: Multiple-choice queries; missing diagnosis; nonleading queries; clinical indicators; compliance.
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NEW QUESTION # 147
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