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| Section | Weight | Objectives |
|---|---|---|
| Professionalism, ethics, and compliance | 9.17% | - DRG compliance initiatives - Medical record confidentiality - Potential DRG creep - CDI department goals beyond reimbursement - Leading queries - Compliance risks indicated by PEPPER |
| Healthcare facility CDI program analysis | 8.33% | - Provider response rates - Patient Safety Indicators - CDI specialist productivity metrics - Physician performance measurement - Tracking and trending physician, department, and hospital performance - CDI program forecasting - PEPPER data - Publicly reported data - Basic computer and software application skills - Case mix index (CMI) - Hospital Value-Based Purchasing measures - High-frequency DRGs - Hospital-specific financial data - CC/MCC capture - Severity of illness and risk of mortality |
| Communication skills | 9.17% | - Verbal versus written physician communication - Effective and non-confrontational physician communication - Roles and responsibilities of coders working with CDI departments - Physician education forms and tools - Reconciling CDI working DRGs with final coded DRGs - Roles and responsibilities of CDI specialists - Educational presentations for healthcare departments and administration |
| Official Guidelines for Coding and Reporting | 14.17% | - AHA Coding Clinic - Coding guidelines for principal diagnosis selection - Hospital-acquired conditions - Present on admission indicators - Secondary diagnosis assignment - Discharge dispositions and transfers - Working DRG assignment for multiple diagnoses - Official Guidelines for Coding and Reporting updates - Principal diagnosis assignment |
| Impact of reportable diagnoses on quality of care | 8.33% | - Hospital Readmissions Reduction Program - Patient Safety Indicators - Healthcare-associated infections and complication codes - Hospital-Acquired Condition Reduction Program - Hospital Value-Based Purchasing - CDI impact on Hospital Value-Based Purchasing - 30-day mortality measures - Mortality reviews and observed/expected ratios - Hospital Inpatient Quality Reporting Program - Documentation and code assignment impact on mortality index - Quality data from record abstraction and claims data - Coded data elements affecting Patient Safety Indicators |
| Medical record documentation | 19.17% | - Situations in which queries are not appropriate - Documentation requiring clarification - Translating clinical indicators into compliant queries - Types of physician queries - ACDIS/AHIMA Guidelines for Achieving a Compliant Query Practice - Addressing diagnoses without clinical support - Compliant and noncompliant queries - Clinical indicators - Physician query formats - When a physician query is warranted - Health record elements used for diagnosis and procedure code assignment - Provider role and diagnosis code assignment |
| Anatomy and physiology, pathophysiology, pharmacology, and medical terminology | 19.17% | - Diseases and disorders of the digestive system - Standard medical abbreviations - Diseases and disorders of the blood and blood-forming organs and immunological disorders - Diseases and disorders of the circulatory system - Endocrine, nutritional, and metabolic diseases and disorders - Clinical indicators and query opportunities by Major Diagnostic Category - Diseases and disorders of the nervous system - Myeloproliferative diseases and disorders and poorly differentiated neoplasms - Diseases and disorders of the skin, subcutaneous tissue, and breast - Medications as clinical indicators - Injuries, poisonings, and toxic effects of drugs - HIV infections - Diseases and disorders of the musculoskeletal system - Diseases and disorders of the hepatobiliary system - Mental diseases and disorders - Diseases and disorders of the respiratory system - Alcohol/drug use and alcohol/drug-induced organic brain disorders - Diagnostic tests as clinical indicators - Pharmaceuticals and disease processes - Diseases and disorders of the kidney and urinary tract - Infectious and parasitic diseases |
| 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 - Complication/comorbidity (CC) - Documentation impact on IPPS reimbursement - Case mix index (CMI) - Medicare Severity Diagnosis Related Groups (MS-DRGs) - Inpatient admission criteria and CMS Two-Midnight Rule - Medical staff and clinical staff documentation responsibilities - Coding and billing practices vulnerable to denial - IPPS and its updates and revisions - Major complication/comorbidity (MCC) - Principal diagnosis and medical necessity |
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NEW QUESTION # 91
The amount of the IPPS Indirect Medical Education Adjustment is determined by teaching intensity as measured by the hospital's number of residents compared to:
Answer: A
Explanation:
Medicare's Indirect Medical Education (IME) adjustment uses the hospital's resident-to-bed ratio as the principal measure of teaching intensity. CMS explains that the IME adjustment factor is calculated using a hospital's ratio of residents to beds. Therefore, the correct answer is inpatient beds.
IME is an additional IPPS payment intended to recognize the higher indirect patient-care costs associated with operating an approved teaching program. These costs are distinguished from Direct Graduate Medical Education payments, which reimburse qualifying direct costs associated with residency training.
The number of admissions is not the denominator in the IME teaching-intensity calculation. Likewise, emergency-department beds are not simply combined with inpatient beds for the standard resident-to-bed ratio, and disproportionate-share payment rates represent a separate IPPS adjustment related principally to hospitals caring for substantial numbers of low-income patients.
For the CCDS examination, the important distinction is that IPPS reimbursement involves more than the base MS-DRG payment. Adjustments may include IME, disproportionate-share hospital provisions, wage-index effects, outlier payments, and other statutory mechanisms.
CCDS Reference Topics: IPPS reimbursement; teaching hospitals; IME adjustment; resident-to-bed ratio.
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NEW QUESTION # 92
Which CMS resource contains the complete FY 2026 lists of diagnoses classified as MCCs and CCs for MS- DRG purposes?
Answer: D
Explanation:
CMS publishes the complete MCC and CC lists as part of the FY 2026 IPPS Final Rule supporting tables.
Specifically, the FY 2026 final-rule page identifies Table 6I as the Complete MCC List and Table 6J as the Complete CC List, along with additions, deletions, and the CC exclusion list.
These files are critical reference resources when assessing MS-DRG severity logic. Nevertheless, classification as an MCC or CC does not automatically mean that the diagnosis changes a particular case's MS-DRG. Principal-diagnosis exclusions, procedure logic, DRG structure, and the presence of another MCC can affect whether a diagnosis alters final assignment.
The Hospital Consumer Assessment survey relates to patient experience rather than diagnosis severity classification. The Physician Fee Schedule governs professional reimbursement and does not contain the inpatient MS-DRG MCC/CC classification system. National Coverage Determinations address Medicare coverage for particular services rather than MS-DRG severity categories.
CDI specialists should use the current CMS version applicable to the discharge date. CMS identifies MS- DRG Version 43.1 as effective April 1 through September 30, 2026.
CCDS Reference Topics: MCC; CC; CMS Definitions Manual; IPPS; MS-DRG severity.
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NEW QUESTION # 93
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: A
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 # 94
Which of the following is a characteristic of a reportable secondary diagnosis?
Answer: B
Explanation:
Increased nursing care is specifically included in the UHDDS/ICD-10-CM definition of a clinically significant reportable secondary diagnosis. A secondary condition is reportable when it affects patient care by requiring clinical evaluation, therapeutic treatment, diagnostic procedures, an extended length of stay, or increased nursing care and/or monitoring.
This distinction prevents conditions that merely appear in the record but have no relevance to the current encounter from automatically becoming reportable secondary diagnoses. For example, a historical diagnosis that does not influence treatment, monitoring, evaluation, or length of stay generally should not be coded simply because it appears in a problem list.
Option A is imprecise. A secondary condition may extend the hospitalization, but it does not need to be the condition that originally "required hospital stay." Option B is the opposite of the guideline criterion, which refers to extended, not decreased, length of stay. Option C is also insufficient by itself: provider documentation establishes diagnoses, but documentation alone does not necessarily make every historical or clinically irrelevant condition reportable.
CDI specialists must therefore evaluate both provider documentation and the clinical significance of secondary conditions.
CCDS Reference Topics: Reporting additional diagnoses; UHDDS; secondary diagnosis criteria; resource utilization.
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NEW QUESTION # 95
Which of the following programs specifically reduces applicable Medicare payments by 1% for hospitals in the worst-performing quartile based on hospital-acquired-condition measures?
Answer: C
Explanation:
The Hospital-Acquired Condition Reduction Program (HACRP) imposes a 1% reduction in applicable Medicare fee-for-service payments on subsection (d) hospitals ranking in the worst-performing quartile based on the Total HAC Score.
For the current program, CMS uses six measures: the CMS Patient Safety and Adverse Events Composite (PSI 90) and five healthcare-associated infection measures-CLABSI, CAUTI, specified surgical-site infection, MRSA bacteremia, and C. difficile infection.
HACRP must be distinguished from the separate DRA Hospital-Acquired Condition/Present-on-Admission payment provision. CMS explicitly states that these are different programs.
Hospital Value-Based Purchasing also links quality performance with hospital payment, but its structure is different: it is funded through a 2% reduction of participating hospitals' base operating DRG payments that is redistributed through value-based incentives.
For CDI professionals, accurate clinical documentation helps ensure that quality data appropriately represent the patient's condition and hospital course. CDI should not attempt to suppress valid complications or create unsupported comorbidities to change quality performance.
CCDS Reference Topics: HACRP; PSI 90; HAIs; quality reimbursement; CMS quality programs.
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NEW QUESTION # 96
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