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| Section | Weight | Objectives |
|---|---|---|
| Topic 1: Healthcare facility CDI program analysis | 8.33% | - PEPPER data - Severity of illness and risk of mortality - Provider response rates - Basic computer and software application skills - Hospital-specific financial data - CC/MCC capture - Hospital Value-Based Purchasing measures - Tracking and trending physician, department, and hospital performance - CDI specialist productivity metrics - Case mix index (CMI) - Publicly reported data - CDI program forecasting - Physician performance measurement - Patient Safety Indicators - High-frequency DRGs |
| Topic 2: Communication skills | 9.17% | - Roles and responsibilities of coders working with CDI departments - Roles and responsibilities of CDI specialists - Educational presentations for healthcare departments and administration - Verbal versus written physician communication - Physician education forms and tools - Effective and non-confrontational physician communication - Reconciling CDI working DRGs with final coded DRGs |
| Topic 3: Professionalism, ethics, and compliance | 9.17% | - CDI department goals beyond reimbursement - DRG compliance initiatives - Leading queries - Potential DRG creep - Medical record confidentiality - Compliance risks indicated by PEPPER |
| Topic 4: Medical record documentation | 19.17% | - Physician query formats - Addressing diagnoses without clinical support - Health record elements used for diagnosis and procedure code assignment - When a physician query is warranted - Compliant and noncompliant queries - Translating clinical indicators into compliant queries - Types of physician queries - Documentation requiring clarification - ACDIS/AHIMA Guidelines for Achieving a Compliant Query Practice - Provider role and diagnosis code assignment - Situations in which queries are not appropriate - Clinical indicators |
| Topic 5: Anatomy and physiology, pathophysiology, pharmacology, and medical terminology | 19.17% | - Endocrine, nutritional, and metabolic diseases and disorders - Mental diseases and disorders - Diseases and disorders of the blood and blood-forming organs and immunological disorders - Diseases and disorders of the circulatory system - Pharmaceuticals and disease processes - Infectious and parasitic diseases - Alcohol/drug use and alcohol/drug-induced organic brain disorders - Standard medical abbreviations - Diseases and disorders of the musculoskeletal system - Diseases and disorders of the nervous system - Diseases and disorders of the hepatobiliary system - Diseases and disorders of the skin, subcutaneous tissue, and breast - Injuries, poisonings, and toxic effects of drugs - Diagnostic tests as clinical indicators - Diseases and disorders of the kidney and urinary tract - Diseases and disorders of the respiratory system - HIV infections - Medications as clinical indicators - Diseases and disorders of the digestive system - Myeloproliferative diseases and disorders and poorly differentiated neoplasms - Clinical indicators and query opportunities by Major Diagnostic Category |
| Topic 6: Impact of reportable diagnoses on quality of care | 8.33% | - Coded data elements affecting Patient Safety Indicators - Hospital Inpatient Quality Reporting Program - Documentation and code assignment impact on mortality index - 30-day mortality measures - CDI impact on Hospital Value-Based Purchasing - Hospital Value-Based Purchasing - Quality data from record abstraction and claims data - Hospital-Acquired Condition Reduction Program - Hospital Readmissions Reduction Program - Healthcare-associated infections and complication codes - Mortality reviews and observed/expected ratios - Patient Safety Indicators |
| Topic 7: Healthcare regulations, reimbursement, and documentation requirements related to the IPPS | 12.5% | - Medical staff and clinical staff documentation responsibilities - Medicare contractors and their impact on CDI - Documentation and medical necessity of setting - Complication/comorbidity (CC) - Principal diagnosis and medical necessity - Case mix index (CMI) - Medicare Severity Diagnosis Related Groups (MS-DRGs) - Inpatient admission criteria and CMS Two-Midnight Rule - Coding and billing practices vulnerable to denial - Major complication/comorbidity (MCC) - Documentation impact on IPPS reimbursement - IPPS and its updates and revisions |
| Topic 8: Official Guidelines for Coding and Reporting | 14.17% | - Hospital-acquired conditions - Official Guidelines for Coding and Reporting updates - Present on admission indicators - Discharge dispositions and transfers - AHA Coding Clinic - Secondary diagnosis assignment - Principal diagnosis assignment - Working DRG assignment for multiple diagnoses - Coding guidelines for principal diagnosis selection |
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NEW QUESTION # 77
During one month, a CDI department issued 400 queries. Providers responded to 360 of them. What was the provider query response rate?
Answer: D
Explanation:
Provider query response rate is calculated by dividing the number of answered queries by the total number of queries requiring a response, then multiplying by 100.
360 รท 400 ร 100 = 90%.
Therefore, the provider response rate is 90%.
Response rate measures whether clinicians engage with documentation clarification requests. It should be distinguished from agreement rate, which measures how often the provider's response supports the diagnosis or clarification being considered. A physician can respond appropriately while disagreeing with the proposed diagnostic possibilities, so a lower agreement rate does not necessarily indicate poor engagement.
A CDI manager should also evaluate response timeliness, service-line patterns, unanswered-query aging, escalation frequency, and whether responses result in complete documentation.
A response rate should not be artificially increased by pressuring providers to choose a particular answer.
Current ACDIS/AHIMA guidance emphasizes a compliant clarification process that preserves independent provider judgment.
In mature CDI programs, metrics are best evaluated longitudinally rather than in isolation. Significant changes should be examined for workflow, staffing, education, electronic-query functionality, or physician- engagement factors.
CCDS Reference Topics: Query response rate; CDI metrics; provider engagement; program analysis; communication.
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NEW QUESTION # 78
Which of the following secondary diagnoses has the MOST positive monetary impact on MS-DRG reimbursement?
Answer: D
Explanation:
Among the listed diagnoses, acute diastolic heart failure has the greatest potential MS-DRG impact because ICD-10-CM code I50.31 is classified as an MCC under the FY 2026 CMS MS-DRG system. CMS specifically identifies I50.31 as an MCC, whereas diagnoses classified only as a CC generally produce a lower severity level within DRG families that distinguish no CC/MCC, CC, and MCC cases.
Acute kidney injury, commonly represented by N17.9 when unspecified, is generally a CC rather than an MCC; CMS examples demonstrate N17.9 functioning as a CC in MS-DRG assignment. COPD with acute exacerbation and many delirium diagnoses may also affect severity assignment, but they do not exceed the MCC effect of qualifying acute heart failure in the standard hierarchy represented here.
The wording "monetary impact" must not be interpreted as permission to pursue diagnoses for financial gain.
CDI professionals should query only when clinical indicators justify clarification. Reimbursement is a consequence of accurate documentation and coding, not the clinical justification for creating a diagnosis.
The actual payment impact also depends on the principal diagnosis, existing MCCs, procedures, payer methodology, and final MS-DRG.
CCDS Reference Topics: CC/MCC hierarchy; MS-DRG reimbursement; acute heart failure; compliant CDI practice.
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NEW QUESTION # 79
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: C
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 # 80
A patient is admitted with a stage 2 sacral pressure ulcer. During the hospitalization, the ulcer progresses and is documented as stage 3 at the same site. How should the pressure ulcer be reported?
Answer: A
Explanation:
The FY 2026 ICD-10-CM Official Guidelines specifically address a pressure ulcer that progresses to a higher stage during an inpatient admission. Two codes are assigned: one representing the site and stage present on admission and another representing the same ulcer site at the highest stage documented during the hospitalization.
Therefore, this patient's stage 2 sacral pressure ulcer on admission and subsequent progression to stage 3 must both be represented according to the applicable coding instructions.
The distinction is important for both clinical and quality purposes because the record must accurately show what condition existed when the patient entered the hospital and how the wound subsequently evolved.
Coding only the stage 3 ulcer would lose information about its status at admission. Coding only stage 2 would fail to represent the deterioration that occurred during the stay.
Pressure-ulcer staging is also one of the circumstances in which qualified non-provider clinician documentation, such as wound-care nursing documentation, may be used to establish stage when the diagnosis itself is appropriately documented.
For CDI, accurate wound location, stage, progression, and POA documentation are essential because advanced pressure injuries may influence MS-DRG severity and hospital quality reporting.
CCDS Reference Topics: Pressure ulcers; staging; POA; wound-care documentation; Official Guidelines.
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NEW QUESTION # 81
A patient is admitted with sepsis due to an E. coli urinary tract infection. The provider also documents acute kidney injury due to the sepsis and "severe sepsis without septic shock." Which sequencing is most appropriate?
Answer: C
Explanation:
When severe sepsis is documented, coding requires the underlying systemic infection first, followed by the appropriate severe-sepsis code and additional code(s) for the acute organ dysfunction. Therefore, the sepsis code is sequenced first, followed by the severe-sepsis code and acute kidney injury.
The FY 2026 ICD-10-CM Official Guidelines state that severe sepsis requires at least two codes: one for the underlying systemic infection and another from subcategory R65.2-. Additional codes identify associated acute organ dysfunction. A code from R65.2- cannot serve as the principal diagnosis.
The UTI identifies the localized source but does not replace the systemic infection as principal diagnosis when sepsis is the condition chiefly responsible for admission. Likewise, the AKI is a manifestation of the severe systemic process and is not sequenced before the sepsis in this scenario.
For CDI specialists, the essential documentation element is the relationship between sepsis and the acute organ dysfunction. Organ dysfunction alone does not automatically permit severe-sepsis coding; provider documentation must establish the association when it is not inherent.
CCDS Reference Topics: Sepsis; severe sepsis; organ dysfunction; sequencing; principal diagnosis.
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NEW QUESTION # 82
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