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| Section | Weight | Objectives |
|---|---|---|
| Topic 1: Healthcare facility CDI program analysis | 8.33% | - Publicly reported data - High-frequency DRGs - Tracking and trending physician, department, and hospital performance - CDI program forecasting - PEPPER data - Provider response rates - Severity of illness and risk of mortality - CDI specialist productivity metrics - Patient Safety Indicators - Physician performance measurement - Hospital Value-Based Purchasing measures - CC/MCC capture - Hospital-specific financial data - Case mix index (CMI) - Basic computer and software application skills |
| Topic 2: Anatomy and physiology, pathophysiology, pharmacology, and medical terminology | 19.17% | - Diseases and disorders of the skin, subcutaneous tissue, and breast - Diseases and disorders of the blood and blood-forming organs and immunological disorders - Medications as clinical indicators - Diseases and disorders of the circulatory system - Infectious and parasitic diseases - Diseases and disorders of the digestive system - Endocrine, nutritional, and metabolic diseases and disorders - Clinical indicators and query opportunities by Major Diagnostic Category - Diagnostic tests as clinical indicators - HIV infections - Diseases and disorders of the respiratory system - Diseases and disorders of the kidney and urinary tract - Myeloproliferative diseases and disorders and poorly differentiated neoplasms - Diseases and disorders of the nervous system - Injuries, poisonings, and toxic effects of drugs - Diseases and disorders of the musculoskeletal system - Pharmaceuticals and disease processes - Mental diseases and disorders - Standard medical abbreviations - Diseases and disorders of the hepatobiliary system - Alcohol/drug use and alcohol/drug-induced organic brain disorders |
| Topic 3: Impact of reportable diagnoses on quality of care | 8.33% | - Hospital Inpatient Quality Reporting Program - Mortality reviews and observed/expected ratios - Hospital Readmissions Reduction Program - CDI impact on Hospital Value-Based Purchasing - 30-day mortality measures - Coded data elements affecting Patient Safety Indicators - Quality data from record abstraction and claims data - Patient Safety Indicators - Hospital-Acquired Condition Reduction Program - Documentation and code assignment impact on mortality index - Hospital Value-Based Purchasing - Healthcare-associated infections and complication codes |
| Topic 4: Professionalism, ethics, and compliance | 9.17% | - Potential DRG creep - Compliance risks indicated by PEPPER - Leading queries - DRG compliance initiatives - Medical record confidentiality - CDI department goals beyond reimbursement |
| Topic 5: Medical record documentation | 19.17% | - Situations in which queries are not appropriate - Addressing diagnoses without clinical support - Documentation requiring clarification - ACDIS/AHIMA Guidelines for Achieving a Compliant Query Practice - Health record elements used for diagnosis and procedure code assignment - Compliant and noncompliant queries - Provider role and diagnosis code assignment - When a physician query is warranted - Clinical indicators - Physician query formats - Types of physician queries - Translating clinical indicators into compliant queries |
| Topic 6: Healthcare regulations, reimbursement, and documentation requirements related to the IPPS | 12.5% | - IPPS and its updates and revisions - Documentation and medical necessity of setting - Complication/comorbidity (CC) - Medicare contractors and their impact on CDI - Documentation impact on IPPS reimbursement - Major complication/comorbidity (MCC) - Coding and billing practices vulnerable to denial - Inpatient admission criteria and CMS Two-Midnight Rule - Medical staff and clinical staff documentation responsibilities - Case mix index (CMI) - Principal diagnosis and medical necessity - Medicare Severity Diagnosis Related Groups (MS-DRGs) |
| Topic 7: Official Guidelines for Coding and Reporting | 14.17% | - Coding guidelines for principal diagnosis selection - Principal diagnosis assignment - Working DRG assignment for multiple diagnoses - AHA Coding Clinic - Hospital-acquired conditions - Present on admission indicators - Secondary diagnosis assignment - Discharge dispositions and transfers - Official Guidelines for Coding and Reporting updates |
| Topic 8: Communication skills | 9.17% | - Physician education forms and tools - Educational presentations for healthcare departments and administration - Roles and responsibilities of CDI specialists - Reconciling CDI working DRGs with final coded DRGs - Effective and non-confrontational physician communication - Roles and responsibilities of coders working with CDI departments - Verbal versus written physician communication |
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NEW QUESTION # 56
Which of the following is included among the FY 2026 Hospital-Acquired Condition Reduction Program measures?
Answer: D
Explanation:
CMS PSI 90, the Patient Safety and Adverse Events Composite, is one of the six measures used in the FY
2026 HAC Reduction Program.
CMS states that the program uses one claims-based patient-safety composite-PSI 90-plus five healthcare- associated infection measures: CLABSI, CAUTI, colon and abdominal hysterectomy surgical-site infection, MRSA bacteremia, and C. difficile infection.
Case mix index is an MS-DRG resource-intensity statistic and is not a HACRP quality measure. Query- response rate is an internal CDI performance metric. Patient-experience measures belong to other CMS quality frameworks, including Hospital VBP, rather than constituting a HACRP measure.
For FY 2026, hospitals with Total HAC Scores above the 75th percentile-effectively the worst-performing quartile-are subject to a 1% payment reduction under the program.
A CDI specialist should also distinguish HACRP from the separate HAC/POA payment provision. CMS explicitly identifies them as distinct programs, even though both involve hospital-acquired conditions.
CCDS Reference Topics: HACRP; PSI 90; healthcare-associated infections; patient safety; quality reimbursement.
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NEW QUESTION # 57
A CDI specialist's working MS-DRG differs from the final coder-assigned MS-DRG in 18% of reviewed cases. What is the BEST initial management response?
Answer: C
Explanation:
A significant mismatch rate should trigger structured CDI/coding reconciliation, not an assumption that either department is wrong.
Working MS-DRGs are provisional. Final coding may change because of discharge-summary diagnoses, operative reports, pathology results, late physician clarification, Coding Clinic guidance, sequencing conventions, final procedure coding, CC/MCC exclusions, or other grouper logic unavailable during the concurrent CDI review.
The manager should categorize mismatch causes. Useful categories include principal-diagnosis differences, missed secondary diagnoses, procedure-code differences, coding-guideline interpretation, query results, discharge documentation, and technical grouper issues.
Patterns can then identify whether education is needed for CDI specialists, coding professionals, physicians, or multiple groups.
Requiring coding staff to adopt the CDI working DRG would undermine coding independence and final coding accountability. Excluding mismatches from metrics would conceal an important quality indicator.
CMS confirms that the FY 2026 MS-DRG Definitions Manual contains the complete grouper logic for Version 43.1, making current grouper rules essential when evaluating discrepancies.
CCDS Reference Topics: MS-DRG reconciliation; CDI/coder agreement; program analysis; education; grouper logic.
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NEW QUESTION # 58
Two diagnoses both meet the definition of principal diagnosis and either could appropriately be sequenced first under the circumstances of admission. No specific sequencing instruction directs otherwise. Which rule applies?
Answer: A
Explanation:
When two diagnoses equally meet the definition of principal diagnosis, either condition may be sequenced first when the circumstances of admission, diagnostic workup, and treatment equally support both and no specific coding guideline, tabular instruction, or other sequencing rule directs otherwise.
The principal diagnosis cannot be selected based on which option generates higher payment. Financial outcome is not a legitimate sequencing criterion.
Likewise, chronological age of the diagnosis does not determine principal-diagnosis status. The principal diagnosis is established after study as the condition chiefly responsible for occasioning the admission.
A CDI query may be appropriate when the documentation does not actually establish whether both diagnoses equally occasioned the admission. However, querying simply because one sequencing choice would produce a more favorable MS-DRG is inappropriate.
This scenario tests the distinction between valid coding flexibility and improper reimbursement-driven documentation practices. CDI professionals must understand coding conventions well enough to avoid unnecessary queries while recognizing genuine ambiguity that requires provider clarification.
The FY 2026 MS-DRG grouper and Definitions Manual published by CMS provide the applicable grouper logic for the current fiscal year.
CCDS Reference Topics: Principal diagnosis; equally qualifying diagnoses; sequencing; ethical reimbursement practice.
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NEW QUESTION # 59
A patient is admitted with hypertension and acute systolic heart failure. The provider does not explicitly link the two conditions and does not state that they are unrelated. Which coding principle applies?
Answer: D
Explanation:
ICD-10-CM presumes a causal relationship between hypertension and qualifying heart disease, including heart failure, because the conditions are linked under "hypertension, with" in the Alphabetic Index. The presumed relationship applies unless the provider clearly documents that the heart disease is unrelated to hypertension.
Accordingly, hypertensive heart disease is coded using the appropriate I11.- category, with an additional I50.- code identifying the specific type and acuity of heart failure.
This convention differs from conditions for which ICD-10-CM does not provide a presumed causal link. In those circumstances, provider documentation must explicitly establish the relationship.
The CDI specialist therefore should not routinely query merely to obtain wording such as "hypertensive heart failure" when both hypertension and a qualifying heart-failure diagnosis are already documented and no statement says they are unrelated.
However, CDI may still need clarification when heart-failure type or acuity is incomplete, documentation is contradictory, or the physician expressly disputes a hypertensive relationship.
Recognizing these classification-based presumptions reduces unnecessary queries and supports accurate working-code and MS-DRG assignment.
CCDS Reference Topics: Hypertensive heart disease; heart failure; presumed relationships; coding conventions; query necessity.
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NEW QUESTION # 60
Respiratory failure is documented in a patient's initial progress notes. There are no clinical indicators in the record to support this diagnosis. According to the AHIMA/ACDIS Practice Brief Guidelines for Achieving a Compliant Query Practice, the MOST appropriate action by the CDI specialist is which of the following?
Answer: C
Explanation:
This scenario requires a clinical validation query. The diagnosis of respiratory failure is documented, but the remainder of the record lacks clinical evidence supporting it. CDI should not automatically accept the diagnosis solely because it appears in a progress note, nor should the specialist unilaterally remove or invalidate the provider's diagnosis.
The appropriate process is to present relevant patient-specific clinical information objectively and ask the responsible provider to clarify whether respiratory failure remains clinically appropriate. A compliant validation query should permit the provider to confirm the diagnosis, document another condition, indicate that it was ruled out, or provide another clinically appropriate response.
Looking only for CPAP documentation is inadequate because CPAP can be used for multiple conditions and its presence or absence does not independently determine whether respiratory failure exists. Similarly, simply refusing to code the diagnosis without seeking clarification bypasses the provider's clinical judgment and the organization's validation process.
The 2026 ACDIS/AHIMA query guidance is now the current foundational standard and supersedes earlier versions of the practice brief.
CCDS Reference Topics: Clinical validation; compliant querying; unsupported diagnoses; documentation integrity.
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NEW QUESTION # 61
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