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| Section | Weight | Objectives |
|---|---|---|
| Topic 1: Professionalism, ethics, and compliance | 9.17% | - CDI department goals beyond reimbursement - Medical record confidentiality - Leading queries - DRG compliance initiatives - Compliance risks indicated by PEPPER - Potential DRG creep |
| Topic 2: Impact of reportable diagnoses on quality of care | 8.33% | - Patient Safety Indicators - 30-day mortality measures - Documentation and code assignment impact on mortality index - Hospital Readmissions Reduction Program - Hospital Inpatient Quality Reporting Program - Mortality reviews and observed/expected ratios - Hospital-Acquired Condition Reduction Program - Coded data elements affecting Patient Safety Indicators - Healthcare-associated infections and complication codes - Quality data from record abstraction and claims data - Hospital Value-Based Purchasing - CDI impact on Hospital Value-Based Purchasing |
| Topic 3: Official Guidelines for Coding and Reporting | 14.17% | - AHA Coding Clinic - Official Guidelines for Coding and Reporting updates - Secondary diagnosis assignment - Discharge dispositions and transfers - Present on admission indicators - Working DRG assignment for multiple diagnoses - Coding guidelines for principal diagnosis selection - Principal diagnosis assignment - Hospital-acquired conditions |
| Topic 4: Healthcare facility CDI program analysis | 8.33% | - Patient Safety Indicators - CDI program forecasting - Tracking and trending physician, department, and hospital performance - Severity of illness and risk of mortality - Hospital-specific financial data - CC/MCC capture - Physician performance measurement - Basic computer and software application skills - Provider response rates - CDI specialist productivity metrics - PEPPER data - Hospital Value-Based Purchasing measures - Case mix index (CMI) - Publicly reported data - High-frequency DRGs |
| Topic 5: Anatomy and physiology, pathophysiology, pharmacology, and medical terminology | 19.17% | - Infectious and parasitic diseases - HIV infections - Diseases and disorders of the digestive system - Diseases and disorders of the skin, subcutaneous tissue, and breast - Diseases and disorders of the respiratory system - Pharmaceuticals and disease processes - Mental diseases and disorders - Diseases and disorders of the kidney and urinary tract - Diseases and disorders of the musculoskeletal system - Diseases and disorders of the nervous system - Diseases and disorders of the blood and blood-forming organs and immunological disorders - Standard medical abbreviations - Diseases and disorders of the hepatobiliary system - Diagnostic tests as clinical indicators - Diseases and disorders of the circulatory system - Clinical indicators and query opportunities by Major Diagnostic Category - Endocrine, nutritional, and metabolic diseases and disorders - Myeloproliferative diseases and disorders and poorly differentiated neoplasms - Injuries, poisonings, and toxic effects of drugs - Medications as clinical indicators - Alcohol/drug use and alcohol/drug-induced organic brain disorders |
| Topic 6: Communication skills | 9.17% | - Reconciling CDI working DRGs with final coded DRGs - Verbal versus written physician communication - Roles and responsibilities of coders working with CDI departments - Roles and responsibilities of CDI specialists - Effective and non-confrontational physician communication - Educational presentations for healthcare departments and administration - Physician education forms and tools |
| Topic 7: Healthcare regulations, reimbursement, and documentation requirements related to the IPPS | 12.5% | - Documentation and medical necessity of setting - Medicare contractors and their impact on CDI - Coding and billing practices vulnerable to denial - IPPS and its updates and revisions - Major complication/comorbidity (MCC) - Principal diagnosis and medical necessity - Documentation impact on IPPS reimbursement - Complication/comorbidity (CC) - Medical staff and clinical staff documentation responsibilities - Medicare Severity Diagnosis Related Groups (MS-DRGs) - Case mix index (CMI) - Inpatient admission criteria and CMS Two-Midnight Rule |
| Topic 8: Medical record documentation | 19.17% | - Situations in which queries are not appropriate - Provider role and diagnosis code assignment - Addressing diagnoses without clinical support - Types of physician queries - Physician query formats - Compliant and noncompliant queries - 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 - Translating clinical indicators into compliant queries - Documentation requiring clarification - Clinical indicators |
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NEW QUESTION # 66
A patient with a history of heart failure is admitted with severe dyspnea and bilateral lower-extremity edema.
BNP is 1,000 pg/mL and echocardiography shows an ejection fraction of 25% with left ventricular systolic dysfunction. Which diagnosis should the CDI specialist consider when constructing a clinically supported clarification query?
Answer: B
Explanation:
Acute on chronic systolic heart failure is the intended answer. This scenario is adapted from an official ACDIS CCDS sample question, which uses dyspnea, edema, elevated BNP, reduced ejection fraction, and left- ventricular dysfunction to test appropriate heart-failure clarification.
The ejection fraction of 25% and documented left ventricular systolic dysfunction support a systolic phenotype. The patient's significant dyspnea and edema are consistent with acute decompensation superimposed on the established history of heart failure. Together, these findings create a legitimate opportunity to clarify type and acuity.
The CDI specialist must nevertheless avoid diagnosing acute-on-chronic systolic failure independently. The provider determines whether the findings represent acute decompensation, chronic disease, another heart- failure phenotype, or another explanation entirely.
Option A would require evidence supporting both systolic and diastolic dysfunction. Option B fails to capture the apparent acute decompensation. Option D conflicts with the documented systolic dysfunction and reduced EF.
This question illustrates a frequent CCDS theme: translating clinical indicators into a neutral clarification opportunity rather than assigning a diagnosis based solely on test results.
CCDS Reference Topics: Heart-failure acuity and type; ejection fraction; BNP; compliant query development.
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NEW QUESTION # 67
A patient undergoes abdominal surgery. Two days later, the physician documents "postoperative anemia." The hemoglobin decreased from 12.4 g/dL preoperatively to 8.2 g/dL, but the record does not state whether the anemia represents an expected postoperative condition, acute blood loss anemia, or a complication of surgery. What should the CDI specialist do?
Answer: D
Explanation:
The appropriate action is to query for clarification. A temporal relationship-anemia occurring after surgery- does not automatically establish that a reportable complication occurred. Likewise, a CDI specialist cannot independently translate a substantial hemoglobin decline into acute posthemorrhagic anemia without provider documentation.
The FY 2026 Official Guidelines state that complication-of-care code assignment depends on provider documentation establishing the relationship between the condition and the care or procedure unless the classification specifically instructs otherwise. They also emphasize that not every condition occurring during or following medical care is a complication.
The query could present the preoperative and postoperative hemoglobin values, estimated blood loss, transfusions, clinical monitoring, and treatment. Appropriate response options might include acute blood loss anemia, expected postoperative anemia, another diagnosis, or clinically unable to determine, depending on the record.
Option A overstates causation. Option B independently diagnoses the patient from laboratory findings. Option D is equally inappropriate because clinically significant postoperative anemia may be reportable.
CCDS Reference Topics: Complications of care; postoperative anemia; clinical indicators; cause-and-effect clarification; compliant querying.
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NEW QUESTION # 68
A patient's baseline creatinine is 1.1 mg/dL. On admission it is 1.2 mg/dL, and 36 hours later it rises to 2.4 mg
/dL after prolonged hypotension. Urine output declines substantially. Which condition presents the strongest clarification opportunity?
Answer: D
Explanation:
The abrupt increase in serum creatinine and reduction in urine output strongly support consideration of acute kidney injury (AKI). The patient's creatinine approximately doubled from the established baseline within a short period, and the episode follows significant hypotension, a recognized cause of acute renal hypoperfusion and potentially ischemic tubular injury.
Chronic kidney disease cannot be established from an acute creatinine change alone. CKD requires evidence that renal abnormalities persist chronically, generally over a period of at least several months. End-stage renal disease represents advanced chronic renal failure and is clearly unsupported by this scenario. Nephrotic syndrome would require a different constellation, particularly substantial proteinuria, hypoalbuminemia, and edema.
The CDI specialist should not independently diagnose AKI based solely on laboratory values. Rather, these findings provide the clinical basis for a neutral provider query if the diagnosis has not been documented.
Relevant indicators could include baseline and current creatinine, urine output, hypotension, fluid resuscitation, nephrology assessment, medications, and renal replacement therapy if applicable.
The CCDS competency framework expects candidates to interpret renal laboratory findings and recognize clinically significant documentation opportunities.
CCDS Reference Topics: Acute kidney injury; renal pathophysiology; creatinine trends; clinical indicators.
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NEW QUESTION # 69
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: A
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 # 70
A patient with colon cancer is admitted solely for transfusion and management of anemia caused directly by the malignancy. No chemotherapy-related adverse effect is involved. Which condition is sequenced first?
Answer: B
Explanation:
When the admission is for management of anemia associated directly with the malignancy, and treatment is directed only at the anemia, the malignancy is sequenced as principal diagnosis, followed by the appropriate anemia code.
The FY 2026 Official Guidelines specifically distinguish malignancy-associated anemia from anemia caused by chemotherapy. For anemia associated with the malignancy, the neoplasm is sequenced first. For anemia resulting from an adverse effect of chemotherapy or immunotherapy, the anemia code is sequenced first.
This distinction makes documentation of anemia etiology essential. Phrases such as "anemia in cancer patient" may not clearly establish whether anemia is attributable to malignancy, chemotherapy, bleeding, nutritional deficiency, chronic kidney disease, or another process.
An encounter code for transfusion does not replace the principal-diagnosis rules for an inpatient hospitalization when the underlying reason for treatment is established.
Likewise, weakness is a symptom and would not supersede the definitive documented cancer-related anemia.
CDI professionals should therefore look beyond the fact that transfusion occurred and identify whether the medical record clearly establishes the cause of the anemia.
CCDS Reference Topics: Neoplasm-related anemia; principal diagnosis; sequencing; chemotherapy versus malignancy; medical record specificity.
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NEW QUESTION # 71
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