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| Section | Weight | Objectives |
|---|---|---|
| Topic 1: Healthcare regulations, reimbursement, and documentation requirements related to the IPPS | 12.5% | - Major complication/comorbidity (MCC) - Medical staff and clinical staff documentation responsibilities - Documentation and medical necessity of setting - Principal diagnosis and medical necessity - Inpatient admission criteria and CMS Two-Midnight Rule - IPPS and its updates and revisions - Medicare contractors and their impact on CDI - Medicare Severity Diagnosis Related Groups (MS-DRGs) - Complication/comorbidity (CC) - Case mix index (CMI) - Coding and billing practices vulnerable to denial - Documentation impact on IPPS reimbursement |
| Topic 2: Professionalism, ethics, and compliance | 9.17% | - Potential DRG creep - Compliance risks indicated by PEPPER - Leading queries - DRG compliance initiatives - CDI department goals beyond reimbursement - Medical record confidentiality |
| Topic 3: Impact of reportable diagnoses on quality of care | 8.33% | - Healthcare-associated infections and complication codes - 30-day mortality measures - Mortality reviews and observed/expected ratios - Documentation and code assignment impact on mortality index - CDI impact on Hospital Value-Based Purchasing - Patient Safety Indicators - Hospital-Acquired Condition Reduction Program - Coded data elements affecting Patient Safety Indicators - Hospital Value-Based Purchasing - Hospital Inpatient Quality Reporting Program - Quality data from record abstraction and claims data - Hospital Readmissions Reduction Program |
| Topic 4: Healthcare facility CDI program analysis | 8.33% | - PEPPER data - CC/MCC capture - Physician performance measurement - CDI specialist productivity metrics - Tracking and trending physician, department, and hospital performance - Severity of illness and risk of mortality - High-frequency DRGs - Hospital Value-Based Purchasing measures - Patient Safety Indicators - Publicly reported data - CDI program forecasting - Provider response rates - Basic computer and software application skills - Case mix index (CMI) - Hospital-specific financial data |
| Topic 5: Anatomy and physiology, pathophysiology, pharmacology, and medical terminology | 19.17% | - Alcohol/drug use and alcohol/drug-induced organic brain disorders - Diseases and disorders of the musculoskeletal system - Clinical indicators and query opportunities by Major Diagnostic Category - 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 hepatobiliary system - Diseases and disorders of the circulatory system - Pharmaceuticals and disease processes - Standard medical abbreviations - Infectious and parasitic diseases - Myeloproliferative diseases and disorders and poorly differentiated neoplasms - Diagnostic tests as clinical indicators - Diseases and disorders of the nervous system - Injuries, poisonings, and toxic effects of drugs - HIV infections - Mental diseases and disorders - Medications as clinical indicators - Diseases and disorders of the kidney and urinary tract - Diseases and disorders of the respiratory system - Diseases and disorders of the skin, subcutaneous tissue, and breast - Endocrine, nutritional, and metabolic diseases and disorders |
| Topic 6: Official Guidelines for Coding and Reporting | 14.17% | - Present on admission indicators - Hospital-acquired conditions - Principal diagnosis assignment - Official Guidelines for Coding and Reporting updates - Coding guidelines for principal diagnosis selection - AHA Coding Clinic - Discharge dispositions and transfers - Secondary diagnosis assignment - Working DRG assignment for multiple diagnoses |
| Topic 7: Communication skills | 9.17% | - Physician education forms and tools - Effective and non-confrontational physician communication - Verbal versus written physician communication - Educational presentations for healthcare departments and administration - Reconciling CDI working DRGs with final coded DRGs - Roles and responsibilities of CDI specialists - Roles and responsibilities of coders working with CDI departments |
| Topic 8: Medical record documentation | 19.17% | - Types of physician queries - When a physician query is warranted - ACDIS/AHIMA Guidelines for Achieving a Compliant Query Practice - Compliant and noncompliant queries - Translating clinical indicators into compliant queries - Addressing diagnoses without clinical support - Clinical indicators - Health record elements used for diagnosis and procedure code assignment - Situations in which queries are not appropriate - Documentation requiring clarification - Provider role and diagnosis code assignment - Physician query formats |
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NEW QUESTION # 97
During one month, a CDI department issued 400 queries. Providers responded to 360 of them. What was the provider query response rate?
Answer: D
Explanation:
Provider query response rate is calculated by dividing the number of answered queries by the total number of queries requiring a response, then multiplying by 100.
360 ÷ 400 × 100 = 90%.
Therefore, the provider response rate is 90%.
Response rate measures whether clinicians engage with documentation clarification requests. It should be distinguished from agreement rate, which measures how often the provider's response supports the diagnosis or clarification being considered. A physician can respond appropriately while disagreeing with the proposed diagnostic possibilities, so a lower agreement rate does not necessarily indicate poor engagement.
A CDI manager should also evaluate response timeliness, service-line patterns, unanswered-query aging, escalation frequency, and whether responses result in complete documentation.
A response rate should not be artificially increased by pressuring providers to choose a particular answer.
Current ACDIS/AHIMA guidance emphasizes a compliant clarification process that preserves independent provider judgment.
In mature CDI programs, metrics are best evaluated longitudinally rather than in isolation. Significant changes should be examined for workflow, staffing, education, electronic-query functionality, or physician- engagement factors.
CCDS Reference Topics: Query response rate; CDI metrics; provider engagement; program analysis; communication.
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NEW QUESTION # 98
The attending physician documents morbid obesity. A registered dietitian documents a body mass index of
43.6 kg/m² in the nutritional assessment. Which of the following is the MOST accurate statement?
Answer: C
Explanation:
BMI is one of the explicit ICD-10-CM exceptions permitting code assignment from documentation by a clinician other than the provider responsible for establishing the diagnosis. Therefore, the BMI of 43.6 may be taken from the dietitian's documentation, while the associated diagnosis of morbid obesity is supported by the attending physician's documentation.
The FY 2026 Official Guidelines specifically identify BMI, pressure-ulcer stage, non-pressure ulcer depth, coma scale, NIH Stroke Scale, certain social determinants, laterality, blood alcohol level, and several other elements as information that may be documented by other qualified clinicians. However, the associated diagnosis, such as obesity, must be documented by the patient's provider.
Option C incorrectly gives the dietitian's BMI documentation authority to establish the obesity diagnosis itself. Option D imposes an unnecessary discharge-summary requirement; valid diagnoses may be supported by appropriate provider documentation elsewhere in the health record according to applicable coding rules.
For CDI specialists, the key distinction is between a diagnosis and a permissible clinical detail used to further characterize that diagnosis.
CCDS Reference Topics: BMI; non-provider documentation; obesity; medical-record review; coding documentation exceptions.
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NEW QUESTION # 99
A patient is admitted with sepsis due to an E. coli urinary tract infection. The provider also documents acute kidney injury due to the sepsis and "severe sepsis without septic shock." Which sequencing is most appropriate?
Answer: C
Explanation:
When severe sepsis is documented, coding requires the underlying systemic infection first, followed by the appropriate severe-sepsis code and additional code(s) for the acute organ dysfunction. Therefore, the sepsis code is sequenced first, followed by the severe-sepsis code and acute kidney injury.
The FY 2026 ICD-10-CM Official Guidelines state that severe sepsis requires at least two codes: one for the underlying systemic infection and another from subcategory R65.2-. Additional codes identify associated acute organ dysfunction. A code from R65.2- cannot serve as the principal diagnosis.
The UTI identifies the localized source but does not replace the systemic infection as principal diagnosis when sepsis is the condition chiefly responsible for admission. Likewise, the AKI is a manifestation of the severe systemic process and is not sequenced before the sepsis in this scenario.
For CDI specialists, the essential documentation element is the relationship between sepsis and the acute organ dysfunction. Organ dysfunction alone does not automatically permit severe-sepsis coding; provider documentation must establish the association when it is not inherent.
CCDS Reference Topics: Sepsis; severe sepsis; organ dysfunction; sequencing; principal diagnosis.
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NEW QUESTION # 100
A CDI specialist has been asked to present a report to hospital administration that will demonstrate the CDI program's impact over time. Which of the following reports will BEST accomplish this?
Answer: B
Explanation:
A line graph showing Risk of Mortality (ROM) and Severity of Illness (SOI) by month provides the strongest evidence of program impact over time because it displays longitudinal trends. Hospital leadership can readily determine whether documented patient complexity and risk profiles are increasing, decreasing, or remaining stable and can correlate those trends with CDI interventions.
The CCDS content outline specifically requires CDI specialists to analyze program trends, use SOI/ROM and other program-performance methodologies, create forecasting data, evaluate hospital performance, and track metrics over time. A line graph is particularly appropriate because time is the independent variable and changes from month to month are immediately visible.
An individual specialist's query rate primarily measures productivity or workflow rather than overall organizational impact. A pie graph of unanswered queries provides a snapshot of one process metric, not longitudinal program effectiveness. A presentation of program goals and objectives communicates strategy but does not demonstrate measurable results.
ROM and SOI also connect CDI work to quality and risk-adjustment outcomes, making them particularly meaningful to senior hospital administration.
CCDS Reference Topics: Healthcare facility CDI program analysis; trend analysis; SOI/ROM; physician and hospital performance.
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NEW QUESTION # 101
A patient with severe cachexia and substantial loss of appetite requires pharmacologic treatment to stimulate appetite. Which of the following medications is most commonly associated with this indication?
Answer: C
Explanation:
Megestrol acetate is the correct choice. This item is adapted from an official ACDIS CCDS sample question in the Candidate Handbook, where Megace-megestrol acetate-is identified as the appropriate appetite- stimulating medication.
Megestrol acetate is a synthetic progestational agent with recognized appetite-stimulating effects. Current U.
S. prescribing information specifically identifies megestrol acetate oral suspension for anorexia, cachexia, or significant unexplained weight loss in patients with AIDS. Its use illustrates why CDI specialists need functional knowledge of pharmacology: medication profiles can provide clinically relevant clues to diagnoses under evaluation, although a medication alone never establishes a reportable diagnosis.
Memantine is primarily used in Alzheimer's disease and is not an appetite stimulant. Levothyroxine replaces thyroid hormone in hypothyroidism. Sibutramine was historically used for weight reduction rather than cachexia and is therefore directionally opposite to the desired effect.
In CDI review, identification of megestrol may prompt assessment of the record for malnutrition, cachexia, malignancy-related weight loss, HIV-associated wasting, or another underlying cause, but the provider must document the diagnosis.
CCDS Reference Topics: Pharmacology; cachexia; nutrition disorders; clinical indicators.
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NEW QUESTION # 102
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