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| Section | Weight | Objectives |
|---|---|---|
| Topic 1: Communication skills | 9.17% | - Physician education and effective communication - CDI and coding roles and interdisciplinary collaboration |
| Topic 2: Medical record documentation | 19.17% | - Documentation requirements and diagnosis or procedure code assignment - Documentation clarification and compliant physician queries |
| Topic 3: Official Guidelines for Coding and Reporting | 14.17% | - Principal and secondary diagnosis assignment - Coding guidelines, AHA Coding Clinic, HACs, and POA indicators |
| Topic 4: Professionalism, ethics, and compliance | 9.17% | - Confidentiality, DRG compliance, and ethical CDI practices - Query compliance, DRG creep, and audit risks |
| Topic 5: Impact of reportable diagnoses on quality of care | 8.33% | - Mortality, severity of illness, and risk of mortality - Quality metrics, reporting programs, and financial impact |
| Topic 6: Healthcare regulations, reimbursement, and documentation requirements related to the IPPS | 12.5% | - CC/MCC, CMI, Medicare contractors, and compliance - IPPS, MS-DRGs, reimbursement, and medical necessity |
| Topic 7: Anatomy and physiology, pathophysiology, pharmacology, and medical terminology | 19.17% | - Clinical conditions and clinical indicators - Anatomy, physiology, pathophysiology, pharmacology, and terminology |
| Topic 8: Healthcare facility CDI program analysis | 8.33% | - Data analysis, forecasting, and performance measurement - CDI productivity, provider response, CMI, and program metrics |
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NEW QUESTION # 95
Under the Inpatient Prospective Payment System, the PACT rule affects MS-DRG payment. PACT is an acronym for which of the following?
Answer: B
Explanation:
PACT stands for Post-Acute Care Transfer. The PACT policy is part of Medicare's IPPS transfer-payment framework and can modify the normal full MS-DRG payment when a qualifying inpatient stay ends with an early transfer or discharge to specified post-acute settings.
CMS applies transfer-payment methodology when applicable conditions are met, including circumstances involving selected discharges to skilled nursing facilities, inpatient rehabilitation facilities, long-term care hospitals, psychiatric facilities, and certain home-health arrangements. For home health, the timing and relationship of post-discharge care can be relevant.
The policy exists because a short acute-care hospitalization followed by transfer to another care setting may not involve the same hospital resource utilization as a conventional discharge completing the expected course of inpatient treatment. Accordingly, the transferring hospital may receive a calculated transfer payment rather than the unrestricted full MS-DRG amount.
For CDI professionals, PACT illustrates why accurate discharge disposition and documentation can affect reimbursement even when the principal diagnosis, procedures, CCs, and MCCs are correctly captured.
CCDS Reference Topics: IPPS; MS-DRG reimbursement; discharge disposition; transfer payment policy.
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NEW QUESTION # 96
A patient with metastatic lung cancer is admitted solely for treatment of anemia caused by chemotherapy. The patient receives packed red blood cells and no treatment directed at the malignancy. Which diagnosis should be sequenced first?
Answer: C
Explanation:
When an admission is specifically for treatment of anemia associated with an adverse effect of chemotherapy or immunotherapy, and treatment is directed only at the anemia, the anemia diagnosis is sequenced first.
The FY 2026 ICD-10-CM Official Guidelines distinguish chemotherapy-related anemia from anemia caused directly by the malignancy. For chemotherapy-associated anemia, the anemia code is sequenced first, followed by the appropriate neoplasm code and the applicable adverse-effect code for the antineoplastic drug.
This differs significantly from anemia associated with the malignancy itself. If the patient is admitted solely to manage anemia caused by the malignancy, the malignancy is sequenced first, followed by the anemia-in- neoplastic-disease code.
The adverse-effect code is required to explain the medication-related cause, but it is not sequenced before the manifestation in this scenario because adverse-effect coding follows the nature of the adverse effect first.
For CDI specialists, accurate documentation of the cause of anemia-malignancy, chemotherapy, bleeding, chronic disease, nutritional deficiency, or another condition-is therefore essential because etiologic specificity can directly change sequencing.
CCDS Reference Topics: Chemotherapy adverse effects; anemia; neoplasm coding; principal diagnosis; sequencing.
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NEW QUESTION # 97
An operative report states that the surgeon performed an excisional debridement of a heel wound. The report documents removal of necrotic tissue but does not identify the deepest tissue level removed. What should the CDI specialist clarify?
Answer: B
Explanation:
For excisional debridement, documentation of the deepest tissue level actually removed is essential for accurate ICD-10-PCS procedure assignment. Relevant levels may include skin, subcutaneous tissue, fascia, muscle, or bone.
The presence of a deep wound does not establish that debridement reached the deepest anatomical layer visible in the wound. For example, a wound may extend to muscle while the physician removes only necrotic subcutaneous tissue. Coding must reflect the body part and tissue actually debrided rather than the overall depth of the wound.
Therefore, the CDI specialist should clarify what tissue was excised. Other procedural elements may already be supported by the operative documentation, including the excisional nature of the procedure.
The number of instruments or duration of anesthesia does not determine the applicable body-part value.
Similarly, administrative details have no bearing on procedural specificity.
CDI specialists working with surgical records must understand the distinction between wound description and procedure performance. Accurate procedural documentation can affect ICD-10-PCS coding and ultimately MS-DRG assignment, particularly when an operating-room procedure influences grouper logic.
The CCDS competency framework includes medical-record review and coding/payment implications of inpatient procedures.
CCDS Reference Topics: Excisional debridement; ICD-10-PCS; tissue depth; operative documentation.
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NEW QUESTION # 98
A hospital has a total MS-DRG relative weight of 2,640 for 1,600 inpatient discharges. What is its case mix index?
Answer: A
Explanation:
Case mix index is calculated by dividing the sum of MS-DRG relative weights by the number of inpatient discharges:
2,640 รท 1,600 = 1.65
Therefore, the CMI is 1.65.
CMI represents the average relative resource intensity of the hospital's inpatient cases. It is affected by the types of patients treated, surgical versus medical mix, tertiary services, transplant or trauma volume, documentation specificity, coding accuracy, and annual changes to MS-DRG relative weights and grouper logic.
CMS publishes hospital case-mix information and FY 2026 relative weighting factors through the IPPS Final Rule supporting data. Table 5 contains MS-DRGs and relative weighting factors, while Table 2 contains hospital-specific case-mix information.
A decline in CMI should not automatically be interpreted as a CDI failure. A shift toward lower-complexity cases or changes in service lines can legitimately reduce CMI even with excellent documentation.
CDI managers should therefore trend CMI alongside diagnosis capture, surgical volume, service lines, payer population, coding reconciliation, and quality indicators.
CCDS Reference Topics: Case mix index; MS-DRG relative weight; CDI analytics; hospital performance.
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NEW QUESTION # 99
A physician documents acute kidney injury. The patient's creatinine is 0.8 mg/dL on admission, 0.9 mg/dL the following day, and 0.8 mg/dL at discharge. Urine output remains normal and no renal treatment is provided.
What is the BEST CDI action?
Answer: A
Explanation:
A clinical validation query is appropriate because the documented diagnosis appears inconsistent with the available clinical evidence. The creatinine values remain essentially unchanged, urine output is normal, and there is no apparent treatment or monitoring consistent with acute renal dysfunction.
The CDI specialist cannot simply delete the diagnosis because providers are responsible for establishing diagnoses. Conversely, a diagnosis should not automatically be accepted when substantial clinical evidence raises a legitimate question about its validity.
A compliant query would present the documented AKI together with the pertinent renal findings and request clarification. The provider could confirm AKI and provide supporting clinical reasoning, revise the diagnosis, state that it was ruled out, or document another condition.
Assigning chronic kidney disease would be equally inappropriate because CKD requires evidence of chronic kidney abnormality and cannot be inferred from these laboratory values.
The August 2026 ACDIS/AHIMA query guidance supersedes prior versions and remains the foundational standard for clinical validation and documentation clarification.
Clinical validation protects data integrity because diagnoses influence reimbursement, quality reporting, severity measurement, utilization analysis, and downstream patient information.
CCDS Reference Topics: Clinical validation; AKI; unsupported diagnoses; provider clarification; compliance.
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NEW QUESTION # 100
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