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| Section | Weight | Objectives |
|---|---|---|
| Topic 1: Medical record documentation | 19.17% | - Clinical indicators - Physician query formats - Situations in which queries are not appropriate - Compliant and noncompliant queries - Provider role and diagnosis code assignment - Addressing diagnoses without clinical support - Translating clinical indicators into compliant queries - Health record elements used for diagnosis and procedure code assignment - Types of physician queries - Documentation requiring clarification - ACDIS/AHIMA Guidelines for Achieving a Compliant Query Practice - When a physician query is warranted |
| Topic 2: Healthcare regulations, reimbursement, and documentation requirements related to the IPPS | 12.5% | - Coding and billing practices vulnerable to denial - Medicare contractors and their impact on CDI - Inpatient admission criteria and CMS Two-Midnight Rule - Principal diagnosis and medical necessity - Documentation impact on IPPS reimbursement - Major complication/comorbidity (MCC) - Case mix index (CMI) - Complication/comorbidity (CC) - IPPS and its updates and revisions - Medicare Severity Diagnosis Related Groups (MS-DRGs) - Documentation and medical necessity of setting - Medical staff and clinical staff documentation responsibilities |
| Topic 3: Healthcare facility CDI program analysis | 8.33% | - CDI program forecasting - CC/MCC capture - Severity of illness and risk of mortality - Basic computer and software application skills - Physician performance measurement - Patient Safety Indicators - Provider response rates - Tracking and trending physician, department, and hospital performance - High-frequency DRGs - Case mix index (CMI) - Publicly reported data - CDI specialist productivity metrics - Hospital Value-Based Purchasing measures - PEPPER data - Hospital-specific financial data |
| Topic 4: Impact of reportable diagnoses on quality of care | 8.33% | - Quality data from record abstraction and claims data - 30-day mortality measures - Hospital Inpatient Quality Reporting Program - Patient Safety Indicators - CDI impact on Hospital Value-Based Purchasing - Healthcare-associated infections and complication codes - Mortality reviews and observed/expected ratios - Hospital-Acquired Condition Reduction Program - Coded data elements affecting Patient Safety Indicators - Hospital Readmissions Reduction Program - Hospital Value-Based Purchasing - Documentation and code assignment impact on mortality index |
| Topic 5: Communication skills | 9.17% | - Roles and responsibilities of CDI specialists - Educational presentations for healthcare departments and administration - Roles and responsibilities of coders working with CDI departments - Effective and non-confrontational physician communication - Physician education forms and tools - Reconciling CDI working DRGs with final coded DRGs - Verbal versus written physician communication |
| Topic 6: Professionalism, ethics, and compliance | 9.17% | - DRG compliance initiatives - Leading queries - Compliance risks indicated by PEPPER - Potential DRG creep - CDI department goals beyond reimbursement - Medical record confidentiality |
| Topic 7: Official Guidelines for Coding and Reporting | 14.17% | - Coding guidelines for principal diagnosis selection - Hospital-acquired conditions - AHA Coding Clinic - Secondary diagnosis assignment - Working DRG assignment for multiple diagnoses - Discharge dispositions and transfers - Present on admission indicators - Principal diagnosis assignment - Official Guidelines for Coding and Reporting updates |
| Topic 8: Anatomy and physiology, pathophysiology, pharmacology, and medical terminology | 19.17% | - Pharmaceuticals and disease processes - Diseases and disorders of the respiratory system - Standard medical abbreviations - Diseases and disorders of the circulatory system - HIV infections - Medications as clinical indicators - Diseases and disorders of the hepatobiliary system - 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 skin, subcutaneous tissue, and breast - Clinical indicators and query opportunities by Major Diagnostic Category - Diseases and disorders of the musculoskeletal system - Diseases and disorders of the kidney and urinary tract - Diseases and disorders of the digestive system - Diseases and disorders of the nervous system - Myeloproliferative diseases and disorders and poorly differentiated neoplasms - Diagnostic tests as clinical indicators - Infectious and parasitic diseases - Endocrine, nutritional, and metabolic diseases and disorders - Mental diseases and disorders - Alcohol/drug use and alcohol/drug-induced organic brain disorders |
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質問 # 29
A hospital has 2,500 inpatient discharges and a cumulative MS-DRG relative weight of 4,375. What is the hospital's case mix index?
正解：C
解説：
Case mix index is calculated as:
Total MS-DRG relative weights ÷ Total inpatient discharges
Therefore:
4,375 ÷ 2,500 = 1.75
The hospital's CMI is 1.75.
CMI provides an aggregate indication of the average relative resource intensity of the hospital's inpatient population. Because each MS-DRG carries a relative weight, hospitals treating larger numbers of complex medical or surgical cases typically have higher CMIs than hospitals treating less resource-intensive populations.
CMI is not a direct quality score and should not be interpreted as a pure measure of CDI performance. It can change because of service-line mix, surgical volume, patient acuity, transfers, annual MS-DRG recalibration, coding accuracy, documentation quality, and other operational changes.
CMS maintains the FY 2026 MS-DRG Definitions Manual and grouper logic, currently Version 43.1 for April 1 through September 30, 2026.
A CDI manager should therefore analyze unexpected CMI changes alongside service-line trends, query activity, coding reconciliation, procedure volumes, and diagnosis patterns.
CCDS Reference Topics: CMI; relative weights; CDI analytics; MS-DRGs; trend analysis.
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質問 # 30
A pregnant female presents to the ED with diarrhea, cramps, nausea, and vomiting for the past 12 hours. She was admitted with enteritis due to Clostridium difficile and provided IV fluids. Which of the following coding guidelines applies to determining the principal diagnosis for this patient?
正解：D
解説：
For a pregnant patient, the first coding consideration is the Chapter 15 obstetric guideline unless the provider explicitly documents that the pregnancy is incidental to the encounter. ICD-10-CM codes from O00-O9A have sequencing priority over codes from other chapters when a condition complicates pregnancy, childbirth, or the puerperium.
Therefore, although the patient's underlying clinical disease is Clostridium difficile enteritis, the principal- diagnosis analysis begins with the applicable pregnancy-complication code. An additional infectious-disease code would then be used as appropriate to identify the specific infection. The infectious and parasitic disease chapter does not override the obstetric sequencing rules.
Signs such as diarrhea, cramps, nausea, and vomiting are also not the principal coding focus once a definitive diagnosis-C. difficile enteritis-has been established. Similarly, an etiology/manifestation sequencing convention is not the controlling rule in this scenario.
The critical CCDS concept is recognition of chapter-specific sequencing rules. A CDI specialist reviewing pregnant patients must recognize that otherwise standard principal-diagnosis logic may be superseded by obstetric instructions.
CCDS Reference Topics: Official Guidelines for Coding and Reporting-Chapter 15; principal diagnosis selection; chapter-specific sequencing.
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質問 # 31
What type of query is needed to compliantly address a scenario in which clinical indicators of a diagnosis exist, but for which no diagnosis has been documented in the medical record?
正解：D
解説：
A multiple-choice query is appropriate when clinical indicators support the possibility of a condition but the diagnosis itself has not yet been documented. The query may present clinically reasonable diagnostic choices supported by the patient's record while also allowing an alternative response such as "other, please specify" or an inability to determine.
A yes/no query is not the appropriate format for introducing a new, previously undocumented diagnosis.
AHIMA/ACDIS guidance has specifically distinguished this situation from circumstances where yes/no clarification may be used for an already documented condition, POA determination, cause-and-effect clarification, or similar defined purposes.
A clinical-validation query addresses the opposite problem: a diagnosis is already documented, but the health record appears to lack sufficient clinical support for that diagnosis. Therefore, option C does not match the scenario.
A cause-and-effect query would be appropriate when two documented conditions require clarification of their relationship, not when the fundamental issue is the absence of a diagnosis.
Current AHIMA/ACDIS guidance continues to permit multiple-choice queries supported by relevant clinical indicators and emphasizes neutral wording.
CCDS Reference Topics: Compliant query formats; missing diagnosis; clinical validation; nonleading queries.
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質問 # 32
A CDI director wants to evaluate whether physicians are consistently addressing clarification requests. Which metric most directly measures this aspect of physician engagement?
正解：B
解説：
The provider query response rate most directly measures whether physicians are responding to CDI clarification requests. It evaluates participation in the query process regardless of whether the provider agrees with the diagnosis suggested by the clinical circumstances.
This distinction is important. A high agreement rate is not necessarily the goal of a compliant CDI program.
Providers should be free to disagree, document an alternative condition, state that a diagnosis was ruled out, or indicate that the issue cannot be determined. A very high response rate combined with clinically independent responses represents stronger engagement than an artificial focus on agreement.
Case mix index measures the average relative resource intensity of the hospital's MS-DRGs and is influenced by numerous clinical, coding, surgical, and case-mix factors. CC capture reflects diagnosis severity patterns but does not directly demonstrate physician responsiveness. CDI review rate is primarily a departmental workflow/productivity measure.
The official CCDS content outline specifically lists provider response rates, CMI, CDI productivity metrics, physician-performance measurement, and longitudinal trending among CDI program-analysis competencies.
A mature program should analyze response rate by service line, provider, query type, response time, and escalation frequency.
CCDS Reference Topics: Provider response rate; physician engagement; CDI analytics; query metrics; program performance.
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質問 # 33
The progress note on hospital day 2 of a patient's admission states that the patient got up from the bed to go to the bathroom just after housekeeping had mopped the floor. The patient slipped and fell onto the floor, sustaining a broken wrist. The diagnosis of a fractured wrist will:
正解：C
解説：
The fracture occurred after inpatient admission as the result of a hospital fall, placing it within CMS's Hospital-Acquired Condition category for Falls and Trauma when the applicable fracture code is included in the HAC code list. CMS's FY 2026 MS-DRG Definitions Manual continues to identify qualifying fracture codes within HAC 05.
The fracture must still be coded; therefore, option D is incorrect. Because it clearly developed after admission, it would not appropriately receive POA indicator "U," which indicates insufficient documentation to determine whether the condition was present on admission.
For qualifying HAC diagnoses that are not POA, CMS payment logic prevents the hospital from receiving the higher MS-DRG payment that would otherwise result solely from the condition's CC/MCC status. Thus, option B expresses the intended payment effect.
This distinction is central to CDI practice: a hospital-acquired diagnosis does not disappear from the record or coding. It remains reportable for clinical and quality purposes, but certain qualifying HACs are treated differently in MS-DRG payment calculations.
CCDS Reference Topics: HACs; POA indicators; Falls and Trauma; MS-DRG payment adjustment.
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質問 # 34
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CCDSテスト資料の評価システムはスマートで非常に強力です。まず、当社の研究者は、CCDSテスト問題のデータスコアリングシステムが実用性のテストに耐えられるようにするために多大な努力を払ってきました。学習タスクを完了してトレーニング結果を送信すると、評価システムはCCDS試験トレントのマークの統計的評価を迅速かつ正確に実行し始めます。これにより、学習タスクを適切に調整し、対象の学習に集中できますCCDSテストの質問があるタスク。
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