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| Section | Weight | Objectives |
|---|---|---|
| Topic 1: Healthcare facility CDI program analysis | 8.33% | - CDI productivity, provider response, CMI, and program metrics - Data analysis, forecasting, and performance measurement |
| Topic 2: Official Guidelines for Coding and Reporting | 14.17% | - Principal and secondary diagnosis assignment - Coding guidelines, AHA Coding Clinic, HACs, and POA indicators |
| Topic 3: Impact of reportable diagnoses on quality of care | 8.33% | - Mortality, severity of illness, and risk of mortality - Quality metrics, reporting programs, and financial impact |
| Topic 4: Healthcare regulations, reimbursement, and documentation requirements related to the IPPS | 12.5% | - CC/MCC, CMI, Medicare contractors, and compliance - IPPS, MS-DRGs, reimbursement, and medical necessity |
| Topic 5: Professionalism, ethics, and compliance | 9.17% | - Query compliance, DRG creep, and audit risks - Confidentiality, DRG compliance, and ethical CDI practices |
| Topic 6: Anatomy and physiology, pathophysiology, pharmacology, and medical terminology | 19.17% | - Clinical conditions and clinical indicators - Anatomy, physiology, pathophysiology, pharmacology, and terminology |
| Topic 7: Medical record documentation | 19.17% | - Documentation requirements and diagnosis or procedure code assignment - Documentation clarification and compliant physician queries |
| Topic 8: Communication skills | 9.17% | - Physician education and effective communication - CDI and coding roles and interdisciplinary collaboration |
長期的にCCDS学習ガイドを選択することを決めたさまざまな国のお客様に利益をもたらしたいと考えています。そのため、この分野の主要な専門家と協力して学習資料を更新および更新します。弊社の有力な専門家は、この分野の最新情報を提供し、時代に対応し、知識のギャップを埋めることを目指しています。お支払い後、年間を通じて当社からCCDSトレーニング資料の最新バージョンを無料で入手できることを保証できます。国際市場で最高のCCDS準備質問を購入する機会をお見逃しなく。これは時代の進歩にも役立ちます。
質問 # 21
Under the FY 2026 Hospital Value-Based Purchasing Program, hospital performance is organized into which of the following four domains?
正解：A
解説：
For FY 2026, CMS Hospital Value-Based Purchasing performance is organized into four domains: Clinical Outcomes; Person and Community Engagement; Safety; and Efficiency and Cost Reduction. CMS reports that each domain contributes to the hospital's Total Performance Score, with the FY 2026 dataset showing weighted scores for all four domains.
The Hospital VBP Program is funded by reducing participating hospitals' base operating DRG payments by
2% and redistributing the amount through value-based incentive payments according to program performance.
CDI professionals are particularly relevant to quality reporting because complete and accurate documentation can influence coded clinical information used in mortality, complications, risk adjustment, patient-safety analysis, and other quality processes. Documentation integrity should not be manipulated to improve scores; rather, the health record must accurately reflect the patient's actual severity and clinical course.
ACDIS explicitly includes Hospital VBP measures, SOI/ROM, Patient Safety Indicators, and publicly reported quality data within CCDS program-analysis competencies.
CCDS Reference Topics: Hospital VBP; quality reporting; Safety domain; Clinical Outcomes; CDI impact on publicly reported data.
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質問 # 22
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?
正解：B
解説：
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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質問 # 23
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?
正解：C
解説：
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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質問 # 24
A CDI program plans to develop a policy for addressing diagnoses that require clinical validation. According to the Guidelines for Achieving a Compliant Query Practice, which of the following should be addressed in the policy?
正解：A
解説：
A compliant clinical-validation process should include a defined escalation process. The AHIMA/ACDIS query guidance specifically recommends organizational query policies that address escalation when a query remains unanswered or when documentation and clinical-validation concerns cannot be resolved through the ordinary workflow. Escalation may involve CDI or coding leadership, a physician advisor, the chief medical officer, or other designated personnel according to organizational policy.
Option A is inappropriate because simply coding every documented diagnosis without addressing significant clinical-support concerns undermines data integrity and increases denial and compliance risk. Option B is also too absolute. Coding professionals cannot independently substitute their clinical judgment for that of the responsible provider; unclear or potentially unsupported diagnoses should be addressed through an established clarification and validation process. Option D is incorrect because queries may appropriately occur concurrently or retrospectively depending on the circumstances and organizational workflow.
The goal of clinical validation is not to force removal or confirmation of a diagnosis. It is to ensure that the provider has an opportunity to clarify whether the diagnosis accurately represents the patient's clinical condition and to document supporting reasoning where appropriate.
CCDS Reference Topics: Professionalism, ethics, and compliance; clinical validation; compliant query policies; escalation procedures.
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質問 # 25
A patient is admitted with nausea, confusion, and generalized weakness. Laboratory testing shows a serum sodium level of 119 mEq/L. The patient receives hypertonic saline and frequent serum sodium monitoring.
The physician documents "electrolyte disturbance." Which condition is the MOST appropriate clarification opportunity?
正解：B
解説：
The clinical findings strongly support clarification of hyponatremia. A serum sodium concentration of 119 mEq/L represents substantial reduction below the usual reference range, and neurologic manifestations such as confusion are consistent with clinically significant hyponatremia. Administration of hypertonic saline and frequent sodium monitoring further demonstrate that the electrolyte abnormality is clinically important.
The CDI specialist should not independently assign the diagnosis based solely on the laboratory result.
Instead, the abnormal sodium level, neurologic symptoms, and targeted therapy provide an appropriate clinical basis for a neutral provider query.
Hypernatremia represents elevated serum sodium and therefore contradicts the laboratory finding.
Hyperkalemia relates to potassium rather than sodium. Metabolic alkalosis is an acid-base disturbance requiring supporting blood-gas and chemistry findings and is not established by the information provided.
Further specificity may also matter. Depending on the clinical record, the physician may determine that the hyponatremia is related to SIADH, volume depletion, medication use, heart failure, cirrhosis, or another etiology.
The CCDS role is to recognize the clinical significance of laboratory abnormalities and obtain clinically meaningful provider documentation rather than simply translating abnormal values into diagnoses.
CCDS Reference Topics: Electrolyte abnormalities; hyponatremia; laboratory interpretation; clinical indicators; documentation clarification.
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質問 # 26
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