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| Section | Weight | Objectives |
|---|---|---|
| Topic 1: Communication skills | 9.17% | - CDI and coding roles and interdisciplinary collaboration - Physician education and effective communication |
| Topic 2: Professionalism, ethics, and compliance | 9.17% | - Query compliance, DRG creep, and audit risks - Confidentiality, DRG compliance, and ethical CDI practices |
| Topic 3: Healthcare facility CDI program analysis | 8.33% | - CDI productivity, provider response, CMI, and program metrics - Data analysis, forecasting, and performance measurement |
| Topic 4: Medical record documentation | 19.17% | - Documentation clarification and compliant physician queries - Documentation requirements and diagnosis or procedure code assignment |
| Topic 5: Official Guidelines for Coding and Reporting | 14.17% | - Coding guidelines, AHA Coding Clinic, HACs, and POA indicators - Principal and secondary diagnosis assignment |
| Topic 6: Impact of reportable diagnoses on quality of care | 8.33% | - Quality metrics, reporting programs, and financial impact - Mortality, severity of illness, and risk of mortality |
| Topic 7: Healthcare regulations, reimbursement, and documentation requirements related to the IPPS | 12.5% | - IPPS, MS-DRGs, reimbursement, and medical necessity - CC/MCC, CMI, Medicare contractors, and compliance |
| Topic 8: Anatomy and physiology, pathophysiology, pharmacology, and medical terminology | 19.17% | - Anatomy, physiology, pathophysiology, pharmacology, and terminology - Clinical conditions and clinical indicators |
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NEW QUESTION # 149
A 34-year-old female was admitted from a group home with uncontrolled diabetes. A CDI specialist must query to specify the patient's mental incapacity since it makes management of the diabetes more difficult.
Which of the following terminology recognized by ICD-10-CM could result in the assignment of a comorbid condition?
Answer: D
Explanation:
Severe intellectual disability is recognized ICD-10-CM terminology and maps to F72, Severe intellectual disabilities. The other phrases are not equivalent standardized ICD-10-CM diagnostic terminology.
This distinction is highly relevant to CDI. Terms used conversationally in the clinical record do not necessarily provide sufficient specificity or map cleanly to reportable ICD-10-CM diagnoses. When a patient's cognitive or developmental condition affects treatment, monitoring, self-management, nursing requirements, or the complexity of care, the CDI specialist should seek clinically appropriate provider documentation using recognized diagnostic terminology.
For FY 2026 MS-DRG logic, CMS identifies F72 as a CC, meaning it can qualify as a complication
/comorbidity when it meets secondary-diagnosis reporting requirements. That does not mean the CDI specialist should query merely for reimbursement impact. The query must be clinically justified by the record and should allow the provider to determine the correct diagnosis.
"Severe mental challenge," "acute mental incapacity," and "acute intellectual disability" do not represent the same codable disease classification.
CCDS Reference Topics: Medical terminology; mental/behavioral and neurodevelopmental disorders; CC recognition; clinically supported query opportunities.
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NEW QUESTION # 150
Which of the following diagnoses is classified as a major complication/comorbidity (MCC) under the FY
2026 MS-DRG system?
Answer: B
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 # 151
A patient without chronic hypercapnia develops severe respiratory distress. ABG results are pH 7.19, PaCO#
74 mmHg, and PaO# 60 mmHg. The patient requires emergent BiPAP. Which condition is MOST strongly supported for clarification?
Answer: C
Explanation:
The findings strongly support clarification of acute hypercapnic respiratory failure. PaCO# of 74 mmHg represents marked carbon dioxide retention, while pH 7.19 demonstrates significant respiratory acidemia. The patient is also hypoxemic and requires urgent noninvasive ventilatory assistance.
Because there is no documented chronic hypercapnic baseline, the available information primarily supports an acute process rather than chronic respiratory failure.
Acute hypercapnia occurs when alveolar ventilation becomes insufficient to eliminate carbon dioxide.
Potential causes include COPD or asthma exacerbation, central nervous system depression, neuromuscular weakness, obesity hypoventilation, airway obstruction, or severe fatigue.
BiPAP provides positive-pressure ventilatory support and can improve alveolar ventilation, decrease work of breathing, and lower PaCO#.
The CDI specialist should not independently establish respiratory failure solely from an ABG. However, the combination of severe physiologic abnormality, respiratory distress, and escalation to BiPAP supplies a strong basis for provider clarification when no corresponding diagnosis is documented.
Metabolic alkalosis would ordinarily involve primary bicarbonate elevation with alkalemia rather than profound respiratory acidemia.
CCDS Reference Topics: Acute respiratory failure; hypercapnia; ABG interpretation; noninvasive ventilation; clinical indicators.
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NEW QUESTION # 152
Which of the following programs specifically reduces applicable Medicare payments by 1% for hospitals in the worst-performing quartile based on hospital-acquired-condition measures?
Answer: A
Explanation:
The Hospital-Acquired Condition Reduction Program (HACRP) imposes a 1% reduction in applicable Medicare fee-for-service payments on subsection (d) hospitals ranking in the worst-performing quartile based on the Total HAC Score.
For the current program, CMS uses six measures: the CMS Patient Safety and Adverse Events Composite (PSI 90) and five healthcare-associated infection measures-CLABSI, CAUTI, specified surgical-site infection, MRSA bacteremia, and C. difficile infection.
HACRP must be distinguished from the separate DRA Hospital-Acquired Condition/Present-on-Admission payment provision. CMS explicitly states that these are different programs.
Hospital Value-Based Purchasing also links quality performance with hospital payment, but its structure is different: it is funded through a 2% reduction of participating hospitals' base operating DRG payments that is redistributed through value-based incentives.
For CDI professionals, accurate clinical documentation helps ensure that quality data appropriately represent the patient's condition and hospital course. CDI should not attempt to suppress valid complications or create unsupported comorbidities to change quality performance.
CCDS Reference Topics: HACRP; PSI 90; HAIs; quality reimbursement; CMS quality programs.
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NEW QUESTION # 153
Under the FY 2026 Hospital-Acquired Condition Reduction Program, which hospitals are subject to the program's payment reduction?
Answer: B
Explanation:
Under the FY 2026 Hospital-Acquired Condition Reduction Program (HACRP), applicable subsection (d) hospitals in the worst-performing quartile based on the Total HAC Score receive a 1% payment reduction on applicable Medicare fee-for-service payments. CMS defines the worst-performing quartile as hospitals whose Total HAC Score is above the 75th percentile.
The FY 2026 program incorporates the CMS Patient Safety and Adverse Events Composite (PSI 90) plus five healthcare-associated infection measures: CLABSI, CAUTI, specified surgical-site infection, MRSA bacteremia, and C. difficile infection.
A single HAC does not automatically trigger the hospital-wide 1% HACRP reduction. Likewise, CMI is not the criterion used to determine HACRP penalties.
It is also important for CCDS candidates to distinguish the HAC Reduction Program from the separate DRA HAC/POA payment provision. CMS explicitly identifies them as distinct programs.
Accurate documentation and coding are important because quality measures rely on reliable clinical data, but CDI activity must remain focused on accurately representing the clinical record rather than manipulating quality metrics.
CCDS Reference Topics: HAC Reduction Program; PSI 90; HAI measures; quality payment; hospital performance.
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NEW QUESTION # 154
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