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| Section | Weight | Objectives |
|---|---|---|
| Topic 1: Professionalism, ethics, and compliance | 9.17% | - Compliance risks indicated by PEPPER - DRG compliance initiatives - CDI department goals beyond reimbursement - Leading queries - Potential DRG creep - Medical record confidentiality |
| Topic 2: Impact of reportable diagnoses on quality of care | 8.33% | - Hospital Inpatient Quality Reporting Program - Documentation and code assignment impact on mortality index - 30-day mortality measures - Coded data elements affecting Patient Safety Indicators - Patient Safety Indicators - Mortality reviews and observed/expected ratios - Hospital Value-Based Purchasing - CDI impact on Hospital Value-Based Purchasing - Hospital-Acquired Condition Reduction Program - Quality data from record abstraction and claims data - Hospital Readmissions Reduction Program - Healthcare-associated infections and complication codes |
| Topic 3: Healthcare facility CDI program analysis | 8.33% | - Hospital Value-Based Purchasing measures - PEPPER data - Severity of illness and risk of mortality - CC/MCC capture - Patient Safety Indicators - Publicly reported data - CDI specialist productivity metrics - CDI program forecasting - Physician performance measurement - Basic computer and software application skills - High-frequency DRGs - Provider response rates - Tracking and trending physician, department, and hospital performance - Case mix index (CMI) - Hospital-specific financial data |
| Topic 4: Healthcare regulations, reimbursement, and documentation requirements related to the IPPS | 12.5% | - Principal diagnosis and medical necessity - Coding and billing practices vulnerable to denial - Inpatient admission criteria and CMS Two-Midnight Rule - Complication/comorbidity (CC) - Medical staff and clinical staff documentation responsibilities - Documentation and medical necessity of setting - Documentation impact on IPPS reimbursement - Major complication/comorbidity (MCC) - Medicare Severity Diagnosis Related Groups (MS-DRGs) - IPPS and its updates and revisions - Case mix index (CMI) - Medicare contractors and their impact on CDI |
| Topic 5: Communication skills | 9.17% | - Roles and responsibilities of coders working with CDI departments - Physician education forms and tools - Educational presentations for healthcare departments and administration - Effective and non-confrontational physician communication - Roles and responsibilities of CDI specialists - Verbal versus written physician communication - Reconciling CDI working DRGs with final coded DRGs |
| Topic 6: Medical record documentation | 19.17% | - Types of physician queries - Translating clinical indicators into compliant queries - Health record elements used for diagnosis and procedure code assignment - Documentation requiring clarification - Addressing diagnoses without clinical support - Provider role and diagnosis code assignment - Compliant and noncompliant queries - Clinical indicators - When a physician query is warranted - Situations in which queries are not appropriate - ACDIS/AHIMA Guidelines for Achieving a Compliant Query Practice - Physician query formats |
| Topic 7: Official Guidelines for Coding and Reporting | 14.17% | - Principal diagnosis assignment - Working DRG assignment for multiple diagnoses - AHA Coding Clinic - Coding guidelines for principal diagnosis selection - Official Guidelines for Coding and Reporting updates - Secondary diagnosis assignment - Present on admission indicators - Discharge dispositions and transfers - Hospital-acquired conditions |
| Topic 8: Anatomy and physiology, pathophysiology, pharmacology, and medical terminology | 19.17% | - Diseases and disorders of the digestive system - Diseases and disorders of the blood and blood-forming organs and immunological disorders - Diseases and disorders of the nervous system - Injuries, poisonings, and toxic effects of drugs - Diagnostic tests as clinical indicators - Myeloproliferative diseases and disorders and poorly differentiated neoplasms - HIV infections - Mental diseases and disorders - Infectious and parasitic diseases - Medications as clinical indicators - Diseases and disorders of the kidney and urinary tract - Diseases and disorders of the skin, subcutaneous tissue, and breast - Diseases and disorders of the hepatobiliary system - Diseases and disorders of the respiratory system - Diseases and disorders of the circulatory system - Alcohol/drug use and alcohol/drug-induced organic brain disorders - Pharmaceuticals and disease processes - Diseases and disorders of the musculoskeletal system - Standard medical abbreviations - Clinical indicators and query opportunities by Major Diagnostic Category - Endocrine, nutritional, and metabolic diseases and disorders |
短時間で試験に合格して認定資格を取得する場合は、適切なCCDS試験問題を選択することが非常に重要です。 CCDS学習資料にもっと注意を払う必要があります。 。すべてのお客様に適切な学習教材を提供するために、当社の多くの専門家がCCDSトレーニング教材を設計しました。 CCDS試験の質問を購入すると、CCDS試験に合格して認定資格を取得するのが非常に簡単になると約束できます。
質問 # 17
Documentation indicates an excisional debridement was performed without further specification. The CDI specialist should query to clarify which of the following?
正解：A
解説：
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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質問 # 18
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?
正解：A
解説：
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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質問 # 19
A patient has hypertension and acute on chronic diastolic heart failure documented during the same admission. The physician does not explicitly link the conditions and does not state that they are unrelated.
Which statement is MOST accurate?
正解：D
解説：
ICD-10-CM generally presumes a causal relationship between hypertension and qualifying heart disease, including heart failure, when both are documented and the provider has not stated that they are unrelated.
The appropriate hypertensive heart-disease code is assigned together with an additional I50.- code identifying the specific heart-failure type and acuity.
The presumption is not limited to systolic heart failure. Diastolic and combined heart-failure diagnoses are included when they meet the applicable classification rules.
Therefore, a query solely asking the physician to state that hypertension caused the heart failure is generally unnecessary when both conditions are documented and no contradictory statement exists.
CDI should nevertheless query if the heart-failure type or acuity is unclear, documentation conflicts, or the provider explicitly indicates another relationship that affects classification.
Understanding presumed relationships is important because unnecessary queries consume physician time and create avoidable administrative work. CDI specialists must distinguish clinical relationships that require explicit provider linkage from those supplied by ICD-10-CM conventions.
CCDS Reference Topics: Hypertensive heart disease; heart failure; presumed causal relationship; coding conventions; query reduction.
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質問 # 20
A patient with dysphagia after a recent stroke develops fever, hypoxia, and a right lower-lobe infiltrate. The physician documents "pneumonia." Speech therapy documents repeated aspiration with oral intake. What is the MOST appropriate CDI action?
正解：B
解説：
The record presents a legitimate opportunity to clarify the type or etiology of pneumonia, particularly whether aspiration contributed to the pulmonary infection. Dysphagia following stroke, documented aspiration during oral intake, fever, hypoxia, and a dependent-lobe infiltrate form a clinically relevant pattern.
However, the CDI specialist cannot independently convert unspecified pneumonia into aspiration pneumonia.
Likewise, the speech-language pathologist can provide valuable clinical evidence regarding swallowing dysfunction and aspiration risk, but that documentation does not independently establish the medical diagnosis of aspiration pneumonia for coding purposes.
A compliant query should objectively present the pertinent indicators and allow the provider to identify aspiration pneumonia, another pneumonia type, pneumonitis, another condition, or inability to determine.
Automatically assigning both bacterial and aspiration pneumonia would also be inappropriate because neither bacterial etiology nor a separate second pneumonia diagnosis has been established.
The current ACDIS/AHIMA guidance emphasizes that queries should arise from the clinical record and preserve the provider's independent judgment rather than directing a preferred diagnosis.
CCDS Reference Topics: Pneumonia specificity; aspiration; dysphagia; interdisciplinary documentation; compliant query development.
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質問 # 21
A patient is admitted with confusion and a history of alcoholic cirrhosis. Ammonia level is 100 µ/L and the blood alcohol level is 2.9. Based on these clinical indicators, the CDI specialist should query the physician for which of the following conditions?
正解：A
解説：
Within the answer choices provided by the source question, hepatic failure is the intended clarification because the combination of cirrhosis, confusion, and markedly elevated ammonia suggests clinically significant hepatic dysfunction with an encephalopathic process.
The pathophysiologic concern is impaired hepatic detoxification and/or portosystemic shunting, allowing neurotoxins such as ammonia to accumulate and contribute to altered mental status. Other supportive findings can include asterixis, disorientation, somnolence, abnormal liver synthetic function, jaundice, ascites, and response to lactulose or rifaximin.
A crucial contemporary CDI distinction is that hepatic encephalopathy now has a dedicated ICD-10-CM code, K76.82. Therefore, current documentation practice should seek the diagnosis that most accurately represents the provider's clinical judgment-such as hepatic encephalopathy-rather than automatically equating elevated ammonia with hepatic failure. Hyperammonemia by itself is not diagnostic, and confusion can have multiple etiologies.
Alcohol dependence is addressed separately based on behavioral criteria, while alcohol poisoning requires evidence that the acute alcohol exposure is the cause of toxicity.
CCDS Reference Topics: Cirrhosis; hepatic dysfunction; hepatic encephalopathy; hyperammonemia; clinical validation and specificity.
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質問 # 22
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CCDS模擬テストに関する限り、PDFバージョンは次の2つの側面に関して非常に便利です。一方、PDFバージョンには、CCDSテストトレントの全バージョンから選択された質問の一部が含まれているデモが含まれています。このようにして、実際の準備試験の一般的な理解を得ることができます。これは、適切な試験ファイルの選択に役立つはずです。一方、CCDS準備資料を印刷して、論文とPDF版で試験の勉強をすることができます。このようなメリットがあるので、試してみませんか？
CCDS日本語版参考資料: https://www.mogiexam.com/CCDS-exam.html