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| Section | Weight | Objectives |
|---|---|---|
| Topic 1: Communication skills | 9.17% | - Verbal versus written physician communication - Physician education forms and tools - Reconciling CDI working DRGs with final coded DRGs - Effective and non-confrontational physician communication - Roles and responsibilities of coders working with CDI departments - Educational presentations for healthcare departments and administration - Roles and responsibilities of CDI specialists |
| Topic 2: Professionalism, ethics, and compliance | 9.17% | - Potential DRG creep - Compliance risks indicated by PEPPER - CDI department goals beyond reimbursement - Medical record confidentiality - DRG compliance initiatives - Leading queries |
| Topic 3: Anatomy and physiology, pathophysiology, pharmacology, and medical terminology | 19.17% | - Clinical indicators and query opportunities by Major Diagnostic Category - Diseases and disorders of the skin, subcutaneous tissue, and breast - HIV infections - Diseases and disorders of the hepatobiliary system - Diseases and disorders of the respiratory system - Diagnostic tests as clinical indicators - Diseases and disorders of the digestive system - Diseases and disorders of the blood and blood-forming organs and immunological disorders - Standard medical abbreviations - Injuries, poisonings, and toxic effects of drugs - Diseases and disorders of the musculoskeletal system - Alcohol/drug use and alcohol/drug-induced organic brain disorders - Myeloproliferative diseases and disorders and poorly differentiated neoplasms - Infectious and parasitic diseases - Pharmaceuticals and disease processes - Medications as clinical indicators - Endocrine, nutritional, and metabolic diseases and disorders - Diseases and disorders of the circulatory system - Mental diseases and disorders - Diseases and disorders of the kidney and urinary tract - Diseases and disorders of the nervous system |
| Topic 4: Impact of reportable diagnoses on quality of care | 8.33% | - CDI impact on Hospital Value-Based Purchasing - Documentation and code assignment impact on mortality index - Coded data elements affecting Patient Safety Indicators - Quality data from record abstraction and claims data - Mortality reviews and observed/expected ratios - Hospital Value-Based Purchasing - Healthcare-associated infections and complication codes - Hospital Readmissions Reduction Program - Patient Safety Indicators - 30-day mortality measures - Hospital Inpatient Quality Reporting Program - Hospital-Acquired Condition Reduction Program |
| Topic 5: Official Guidelines for Coding and Reporting | 14.17% | - Principal diagnosis assignment - Discharge dispositions and transfers - Working DRG assignment for multiple diagnoses - Present on admission indicators - Secondary diagnosis assignment - Official Guidelines for Coding and Reporting updates - Coding guidelines for principal diagnosis selection - Hospital-acquired conditions - AHA Coding Clinic |
| Topic 6: Healthcare facility CDI program analysis | 8.33% | - Hospital Value-Based Purchasing measures - CDI program forecasting - CC/MCC capture - Severity of illness and risk of mortality - Publicly reported data - Case mix index (CMI) - CDI specialist productivity metrics - Patient Safety Indicators - PEPPER data - Physician performance measurement - Provider response rates - Basic computer and software application skills - High-frequency DRGs - Tracking and trending physician, department, and hospital performance - Hospital-specific financial data |
| Topic 7: Healthcare regulations, reimbursement, and documentation requirements related to the IPPS | 12.5% | - Medical staff and clinical staff documentation responsibilities - Coding and billing practices vulnerable to denial - Inpatient admission criteria and CMS Two-Midnight Rule - Documentation impact on IPPS reimbursement - Complication/comorbidity (CC) - Medicare contractors and their impact on CDI - Case mix index (CMI) - Principal diagnosis and medical necessity - Medicare Severity Diagnosis Related Groups (MS-DRGs) - Documentation and medical necessity of setting - IPPS and its updates and revisions - Major complication/comorbidity (MCC) |
| Topic 8: Medical record documentation | 19.17% | - Provider role and diagnosis code assignment - Types of physician queries - Documentation requiring clarification - Health record elements used for diagnosis and procedure code assignment - Compliant and noncompliant queries - Addressing diagnoses without clinical support - Physician query formats - Translating clinical indicators into compliant queries - When a physician query is warranted - Situations in which queries are not appropriate - Clinical indicators - ACDIS/AHIMA Guidelines for Achieving a Compliant Query Practice |
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NEW QUESTION # 70
Two MS-DRGs have relative weights of 0.85 and 2.10. Which statement is MOST accurate?
Answer: B
Explanation:
An MS-DRG relative weight principally represents relative expected resource consumption. Therefore, a DRG with a relative weight of 2.10 is associated with greater average resource intensity than one with a relative weight of 0.85.
The weight does not determine the hospital's billed charges, nor is it a direct mortality score. Clinically complex patients may often fall into higher-weight DRGs because they require more resources, but resource intensity, severity of illness, and risk of mortality are conceptually distinct.
The relative weight contributes to IPPS payment calculations when multiplied through the applicable standardized-payment methodology and adjusted by hospital-specific factors and other payment rules.
CMS publishes current MS-DRG weighting factors as part of the FY 2026 IPPS Final Rule materials.
For CDI professionals, understanding relative weight helps explain why accurate diagnoses and procedures can influence reimbursement. However, reimbursement consequences must never become the justification for obtaining unsupported documentation. The objective remains accurate representation of the patient's clinical condition and resources required.
CCDS Reference Topics: Relative weight; resource consumption; IPPS; MS-DRG payment; severity concepts.
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NEW QUESTION # 71
The MOST important factor influencing a hospital's ability to capture the most accurate MS-DRG involves:
Answer: C
Explanation:
Complete clinical documentation is the foundation of accurate MS-DRG assignment. The coding process translates provider documentation into ICD-10-CM and ICD-10-PCS codes, and those codes drive the MS- DRG grouper. If the record does not accurately capture the principal diagnosis, secondary diagnoses, acuity, etiologies, complications, procedures, and clinically relevant relationships, the resulting MS-DRG may not accurately represent the patient's hospitalization.
CMS explains that MS-DRG assignment depends on factors including diagnoses, procedures, complicating conditions, age, sex, and discharge status. Each resulting MS-DRG has a payment weight representing relative resource requirements.
POA documentation is important, particularly for HAC payment logic, but it is only one component of overall documentation completeness. Quality indicators and patient-satisfaction information serve other important organizational purposes but do not substitute for complete provider documentation when grouping the inpatient claim.
The role of CDI is therefore broader than capturing CCs or MCCs. CDI professionals work to ensure that the entire medical record provides a precise clinical description of the patient and services rendered, allowing coding, quality reporting, risk adjustment, utilization review, and reimbursement to be based on the same accurate clinical story.
CCDS Reference Topics: Documentation integrity; MS-DRG assignment; principal/secondary diagnoses; CDI fundamentals.
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NEW QUESTION # 72
A patient who underwent abdominal surgery one week ago is readmitted specifically for treatment of a postoperative wound infection documented by the surgeon as a complication of the procedure. Which condition should generally be considered for principal diagnosis selection?
Answer: B
Explanation:
When a patient is admitted specifically for treatment of a documented postoperative complication, the complication is generally sequenced as the principal diagnosis when it is established after study to be chiefly responsible for the admission.
In this scenario, the surgeon has explicitly documented the wound infection as a complication of the prior procedure, and treatment of that complication is the reason for the current hospitalization. The original surgical disease therefore does not automatically remain the principal diagnosis simply because it led to the earlier operation.
Fever and abdominal pain are clinical manifestations or symptoms and ordinarily are not sequenced ahead of the definitive postoperative infection once that condition has been established.
A critical CDI principle is that a temporal relationship alone is insufficient to classify a postoperative condition as a complication. The provider must establish the appropriate relationship when required by ICD-
10-CM. Here, that documentation is already present, so a query simply asking whether the infection is postoperative would be unnecessary.
The principal-diagnosis decision should still account for all applicable complication-code sequencing instructions and circumstances of admission. The FY 2026 Official Guidelines emphasize both principal- diagnosis rules and requirements surrounding complications of care.
CCDS Reference Topics: Principal diagnosis; postoperative complications; complications of care; sequencing.
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NEW QUESTION # 73
A patient undergoes colorectal surgery. On postoperative day 2, the physician documents "ileus." The record shows absent bowel sounds and abdominal distention, but the surgeon also states that delayed bowel function is expected at this stage of recovery. Which action is MOST appropriate?
Answer: B
Explanation:
The record contains uncertainty regarding whether the documented ileus represents expected postoperative physiology or a clinically significant complication, making provider clarification appropriate.
Temporary impairment of gastrointestinal motility is common following abdominal surgery. Therefore, the mere occurrence of an ileus after surgery does not automatically establish a complication of care. Conversely, prolonged or clinically significant postoperative ileus requiring substantial treatment, extended hospitalization, nasogastric decompression, or other interventions may warrant distinct documentation.
The CDI specialist must not infer the complication relationship solely from timing. The Official Guidelines emphasize that a condition occurring after medical or surgical care is not automatically classified as a complication; appropriate provider documentation of the relationship and clinical significance is required where applicable.
Option C is also incorrect because postoperative ileus can be a reportable condition when clinically significant and appropriately documented. Option D substitutes a separate diagnosis without provider support.
The query should provide relevant duration, symptoms, imaging, diet status, nasogastric tube use, treatment, and expected postoperative course while allowing the surgeon to characterize the condition.
CCDS Reference Topics: Postoperative ileus; complications of care; postoperative documentation; clinical clarification.
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NEW QUESTION # 74
A physician responds to a clinically supported CDI query by stating that the proposed diagnosis does not apply and documents a different diagnosis supported by the patient's condition. What is the BEST action by the CDI specialist?
Answer: A
Explanation:
The CDI specialist should respect the provider's independent clinical judgment, provided the response clearly addresses the query and the resulting documentation is clinically coherent.
A query is a request for clarification-not a mechanism for compelling the provider to select CDI's preferred diagnosis. Physician disagreement is therefore not inherently a failed query. The provider may appropriately document another condition, rule out a suspected condition, or explain why the indicators have another clinical interpretation.
Repeatedly querying until a desired diagnosis appears creates serious compliance risk and can undermine the integrity of the documentation process. Escalation may be appropriate in defined circumstances-for example, unresolved contradictions, unanswered high-priority queries, or persistent clinical-validation issues-but should follow organizational policy and should not occur merely because CDI dislikes the provider's answer.
The 2026 ACDIS/AHIMA guidance is the current foundational query-practice standard and emphasizes compliant clarification across healthcare settings.
Effective CDI communication requires clinical knowledge, professional dialogue, and recognition that final diagnostic determinations belong to the responsible provider.
CCDS Reference Topics: Physician communication; query responses; provider independence; escalation; professional conduct.
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NEW QUESTION # 75
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