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| Section | Weight | Objectives |
|---|---|---|
| Communication skills | 9.17% | - Roles and responsibilities of coders working with CDI departments - Educational presentations for healthcare departments and administration - Verbal versus written physician communication - Roles and responsibilities of CDI specialists - Effective and non-confrontational physician communication - Reconciling CDI working DRGs with final coded DRGs - Physician education forms and tools |
| Healthcare facility CDI program analysis | 8.33% | - High-frequency DRGs - Severity of illness and risk of mortality - Provider response rates - Basic computer and software application skills - Publicly reported data - Tracking and trending physician, department, and hospital performance - Patient Safety Indicators - CDI specialist productivity metrics - Case mix index (CMI) - Hospital Value-Based Purchasing measures - Physician performance measurement - Hospital-specific financial data - CC/MCC capture - CDI program forecasting - PEPPER data |
| Professionalism, ethics, and compliance | 9.17% | - Compliance risks indicated by PEPPER - Leading queries - Medical record confidentiality - CDI department goals beyond reimbursement - Potential DRG creep - DRG compliance initiatives |
| Medical record documentation | 19.17% | - Provider role and diagnosis code assignment - Situations in which queries are not appropriate - Compliant and noncompliant queries - Clinical indicators - When a physician query is warranted - ACDIS/AHIMA Guidelines for Achieving a Compliant Query Practice - Health record elements used for diagnosis and procedure code assignment - Types of physician queries - Documentation requiring clarification - Addressing diagnoses without clinical support - Physician query formats - Translating clinical indicators into compliant queries |
| Impact of reportable diagnoses on quality of care | 8.33% | - Quality data from record abstraction and claims data - Hospital Readmissions Reduction Program - Hospital Inpatient Quality Reporting Program - CDI impact on Hospital Value-Based Purchasing - 30-day mortality measures - Patient Safety Indicators - Hospital Value-Based Purchasing - Coded data elements affecting Patient Safety Indicators - Documentation and code assignment impact on mortality index - Mortality reviews and observed/expected ratios - Hospital-Acquired Condition Reduction Program - Healthcare-associated infections and complication codes |
| Official Guidelines for Coding and Reporting | 14.17% | - AHA Coding Clinic - Present on admission indicators - Working DRG assignment for multiple diagnoses - Principal diagnosis assignment - Hospital-acquired conditions - Coding guidelines for principal diagnosis selection - Secondary diagnosis assignment - Official Guidelines for Coding and Reporting updates - Discharge dispositions and transfers |
| Healthcare regulations, reimbursement, and documentation requirements related to the IPPS | 12.5% | - Principal diagnosis and medical necessity - Complication/comorbidity (CC) - IPPS and its updates and revisions - Inpatient admission criteria and CMS Two-Midnight Rule - Documentation impact on IPPS reimbursement - Medicare contractors and their impact on CDI - Case mix index (CMI) - Documentation and medical necessity of setting - Medicare Severity Diagnosis Related Groups (MS-DRGs) - Major complication/comorbidity (MCC) - Coding and billing practices vulnerable to denial - Medical staff and clinical staff documentation responsibilities |
| Anatomy and physiology, pathophysiology, pharmacology, and medical terminology | 19.17% | - Diseases and disorders of the blood and blood-forming organs and immunological disorders - Diseases and disorders of the nervous system - Pharmaceuticals and disease processes - Myeloproliferative diseases and disorders and poorly differentiated neoplasms - HIV infections - Diseases and disorders of the kidney and urinary tract - Diseases and disorders of the digestive system - Diseases and disorders of the respiratory system - Injuries, poisonings, and toxic effects of drugs - Infectious and parasitic diseases - Diseases and disorders of the hepatobiliary system - Clinical indicators and query opportunities by Major Diagnostic Category - Diseases and disorders of the musculoskeletal system - Diseases and disorders of the skin, subcutaneous tissue, and breast - Standard medical abbreviations - Medications as clinical indicators - Diagnostic tests as clinical indicators - Diseases and disorders of the circulatory system - Mental diseases and disorders - Alcohol/drug use and alcohol/drug-induced organic brain disorders - Endocrine, nutritional, and metabolic diseases and disorders |
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52. Frage
Which of the following diagnoses is classified as a major complication/comorbidity (MCC) under the FY
2026 MS-DRG system?
Antwort: B
Begründung:
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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53. Frage
Under the Hospital Readmissions Reduction Program, what is the maximum payment reduction applicable to an eligible hospital?
Antwort: A
Begründung:
The maximum payment reduction under the Hospital Readmissions Reduction Program is 3%. CMS expresses this through a payment adjustment factor ranging from 1.0, indicating no reduction, to 0.97, representing the maximum 3% reduction.
The HRRP links Medicare payment to excess readmission performance for specified clinical populations.
CMS applies the resulting adjustment to applicable Medicare fee-for-service base operating DRG payments.
This program should not be confused with other Medicare hospital quality-payment initiatives. The HAC Reduction Program imposes a 1% reduction on hospitals in the worst-performing quartile, while Hospital Value-Based Purchasing uses a 2% reduction-and-redistribution mechanism.
CMS's FY 2026 IPPS final rule also finalized changes to HRRP methodology that begin with the FY 2027 program year, including incorporation of Medicare Advantage data into the six readmission measures and shortening the applicable performance period from three years to two.
For CDI, the central obligation remains ensuring that the clinical record accurately portrays patient severity, conditions treated, discharge circumstances, and comorbid disease burden.
CCDS Reference Topics: HRRP; readmission measures; quality reimbursement; payment adjustments; risk adjustment.
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54. Frage
A CDI program reports the following monthly results:
- Provider response rate: 97%
- Provider agreement rate: 84%
- Queries issued after discharge: 38%
- CDI/coder agreement: 96%
Which metric presents the clearest opportunity to improve concurrent CDI workflow?
Antwort: C
Begründung:
The 38% post-discharge query rate represents the clearest workflow opportunity because a large proportion of clarification is occurring after the concurrent hospitalization period.
A 97% provider response rate reflects strong physician participation, while a 96% CDI/coder agreement rate indicates substantial alignment between concurrent CDI review and final coding. An 84% agreement rate is not inherently problematic because providers must remain free to disagree with a query based on their clinical judgment.
A high retrospective-query percentage can indicate that cases are being reviewed too late, that certain documentation opportunities are not recognized during hospitalization, that discharge documentation introduces unresolved diagnoses, or that staffing/workflow does not adequately prioritize cases before discharge.
A CDI manager should drill further into the metric by service line, query type, day of stay, weekday/weekend discharge, provider group, and reason for retrospective clarification. This analysis helps distinguish unavoidable retrospective queries from remediable process problems.
The objective is not to eliminate every post-discharge query. Some documentation issues become apparent only after final testing, pathology, procedures, or discharge summaries are completed.
CCDS Reference Topics: CDI program metrics; concurrent versus retrospective review; workflow analysis; performance improvement.
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55. Frage
A CDI specialist drafts the following query:
"Please document acute respiratory failure because the patient's oxygen saturation is 84% and this diagnosis will qualify as an MCC." What is the MOST appropriate action?
Antwort: B
Begründung:
The query should be rewritten as a neutral, clinically supported clarification request. The original wording is noncompliant because it directs the physician toward a particular diagnosis and explicitly identifies its reimbursement consequence.
The current ACDIS/AHIMA 2026 Guidelines for Achieving a Compliant Query Practice, released in August
2026, supersede prior versions and emphasize that the query process exists to ensure the health record accurately reflects the patient's clinical status.
A compliant query could present relevant findings such as oxygen saturation, respiratory rate, blood-gas values, oxygen requirements, work of breathing, escalation to noninvasive or invasive ventilation, and treatment. It should then request clarification using clinically reasonable choices or another compliant format without highlighting which answer produces an MCC.
An oxygen saturation of 84% may be an important indicator, but a CDI specialist may not convert that finding independently into respiratory failure. The provider must evaluate the complete clinical picture.
Approval from a coding manager does not cure biased wording. Substituting "CC" for "MCC" likewise leaves the fundamental compliance problem intact.
CCDS Reference Topics: Query compliance; leading queries; respiratory failure; ethical CDI practice.
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56. Frage
After a month of intermittent antibiotic use, the patient is admitted. An infectious-control physician documents a diagnosis of Clostridium difficile in the inpatient medical record. Which domain of the MOST current Hospital Value-Based Purchasing program would this diagnosis impact?
Antwort: A
Begründung:
The relevant Hospital Value-Based Purchasing domain is the Safety domain, corresponding most closely to option D. CMS's FY 2026 Hospital VBP program maintains a Safety domain that includes healthcare- associated infection performance measures, including C. difficile infection. CMS's current VBP Safety dataset specifically identifies C. difficile among its healthcare-associated infection measures.
It is important to distinguish the domain from an individual measure. "Hospital-acquired infection" describes the type of quality measure, but the formal broader scoring domain is Safety. PSI 90 is also associated with patient safety measurement, but it is not the name of the overall VBP domain.
From a CDI standpoint, documentation accuracy matters because coded and quality-reporting data can influence organizational performance assessment. However, documentation of C. difficile alone does not automatically establish that an infection qualifies as a hospital-onset event for every quality program. Timing and the applicable measure specifications determine whether an individual episode enters a particular healthcare-associated infection metric.
Therefore, CDI professionals should accurately capture the infection and its clinical circumstances without attempting to classify an event as hospital acquired solely to influence quality scores.
CCDS Reference Topics: Hospital VBP; Safety domain; healthcare-associated infections; C. difficile; quality reporting.
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57. Frage
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