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| Section | Weight | Objectives |
|---|---|---|
| Topic 1: Professionalism, ethics, and compliance | 9.17% | - Medical record confidentiality - Leading queries - Compliance risks indicated by PEPPER - Potential DRG creep - CDI department goals beyond reimbursement - DRG compliance initiatives |
| Topic 2: Medical record documentation | 19.17% | - Health record elements used for diagnosis and procedure code assignment - Physician query formats - Provider role and diagnosis code assignment - Clinical indicators - Translating clinical indicators into compliant queries - ACDIS/AHIMA Guidelines for Achieving a Compliant Query Practice - Addressing diagnoses without clinical support - Compliant and noncompliant queries - Types of physician queries - When a physician query is warranted - Situations in which queries are not appropriate - Documentation requiring clarification |
| Topic 3: Healthcare regulations, reimbursement, and documentation requirements related to the IPPS | 12.5% | - Documentation impact on IPPS reimbursement - Principal diagnosis and medical necessity - Medicare contractors and their impact on CDI - IPPS and its updates and revisions - Documentation and medical necessity of setting - Inpatient admission criteria and CMS Two-Midnight Rule - Medical staff and clinical staff documentation responsibilities - Major complication/comorbidity (MCC) - Case mix index (CMI) - Complication/comorbidity (CC) - Coding and billing practices vulnerable to denial - Medicare Severity Diagnosis Related Groups (MS-DRGs) |
| Topic 4: Anatomy and physiology, pathophysiology, pharmacology, and medical terminology | 19.17% | - Alcohol/drug use and alcohol/drug-induced organic brain disorders - Diagnostic tests as clinical indicators - Diseases and disorders of the nervous system - Diseases and disorders of the skin, subcutaneous tissue, and breast - Endocrine, nutritional, and metabolic diseases and disorders - Diseases and disorders of the circulatory system - Diseases and disorders of the digestive system - Pharmaceuticals and disease processes - Diseases and disorders of the hepatobiliary system - Clinical indicators and query opportunities by Major Diagnostic Category - Mental diseases and disorders - Injuries, poisonings, and toxic effects of drugs - Diseases and disorders of the musculoskeletal system - Diseases and disorders of the respiratory system - HIV infections - Diseases and disorders of the kidney and urinary tract - Medications as clinical indicators - Diseases and disorders of the blood and blood-forming organs and immunological disorders - Standard medical abbreviations - Myeloproliferative diseases and disorders and poorly differentiated neoplasms - Infectious and parasitic diseases |
| Topic 5: Impact of reportable diagnoses on quality of care | 8.33% | - Healthcare-associated infections and complication codes - Documentation and code assignment impact on mortality index - Quality data from record abstraction and claims data - Hospital-Acquired Condition Reduction Program - Patient Safety Indicators - CDI impact on Hospital Value-Based Purchasing - 30-day mortality measures - Hospital Inpatient Quality Reporting Program - Hospital Value-Based Purchasing - Hospital Readmissions Reduction Program - Coded data elements affecting Patient Safety Indicators - Mortality reviews and observed/expected ratios |
| Topic 6: Official Guidelines for Coding and Reporting | 14.17% | - Discharge dispositions and transfers - Principal diagnosis assignment - Coding guidelines for principal diagnosis selection - Official Guidelines for Coding and Reporting updates - Present on admission indicators - Hospital-acquired conditions - Working DRG assignment for multiple diagnoses - Secondary diagnosis assignment - AHA Coding Clinic |
| Topic 7: Healthcare facility CDI program analysis | 8.33% | - Hospital-specific financial data - Patient Safety Indicators - Severity of illness and risk of mortality - Provider response rates - CDI specialist productivity metrics - PEPPER data - Physician performance measurement - Publicly reported data - Hospital Value-Based Purchasing measures - Basic computer and software application skills - Case mix index (CMI) - Tracking and trending physician, department, and hospital performance - CC/MCC capture - High-frequency DRGs - CDI program forecasting |
| Topic 8: Communication skills | 9.17% | - Verbal versus written physician communication - Roles and responsibilities of CDI specialists - Physician education forms and tools - Educational presentations for healthcare departments and administration - Reconciling CDI working DRGs with final coded DRGs - Roles and responsibilities of coders working with CDI departments - Effective and non-confrontational physician communication |
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NEW QUESTION # 127
A CDI specialist reviews a prior hospitalization and finds that the patient previously had chronic systolic heart failure. During the current admission, the provider documents only "history of CHF," although the patient remains on long-term heart-failure therapy. What is the BEST approach?
Answer: A
Explanation:
Prior-encounter information may provide valuable clinical context, but it should not automatically be imported as a current reportable diagnosis without considering whether the condition remains active and relevant to the present encounter.
Here, a prior diagnosis of chronic systolic heart failure, ongoing heart-failure therapy, and ambiguous current wording such as "history of CHF" create a reasonable opportunity to clarify the patient's current heart-failure status if that information is clinically relevant.
The CDI specialist should not independently carry forward the previous diagnosis or escalate it to acute heart failure. Conversely, rigidly ignoring reliable prior clinical information can prevent identification of legitimate documentation gaps.
The 2026 ACDIS/AHIMA query guidance specifically includes the role of prior encounters as part of its updated query-practice framework, while emphasizing compliant provider clarification and accurate representation of the current patient's clinical status.
A query should make clear which current clinical indicators support the need for clarification and should not imply that a previous diagnosis must automatically remain valid.
CCDS Reference Topics: Prior encounters; chronic conditions; heart failure; query practice; current- encounter documentation.
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NEW QUESTION # 128
A patient is admitted with community-acquired pneumonia. On day 3, he begins to show signs of increasing respiratory distress and requires intubation. When he arrives in the ICU, the nurse inserts a urinary catheter and notes that his urine output has decreased. The physician documents respiratory failure and acute renal failure secondary to sepsis caused by pneumonia. The patient's condition would be classified as:
Answer: C
Explanation:
This patient has sepsis with documented acute organ dysfunction, specifically acute respiratory failure and acute renal failure. Under ICD-10-CM coding guidance, sepsis associated with acute organ dysfunction is classified as severe sepsis when the provider establishes the relationship between the systemic infection and the organ dysfunction.
The documentation specifically states that respiratory failure and acute renal failure are secondary to sepsis caused by pneumonia. That causal linkage is critical. FY 2026 Official Guidelines require the underlying systemic infection code, followed by a code from R65.2- for severe sepsis, plus additional codes identifying each associated acute organ dysfunction.
Septic shock is not supported because the scenario does not document circulatory failure attributable to sepsis, persistent hypotension requiring vasopressors, or a provider diagnosis of septic shock. "Septicemia" is also not equivalent terminology for coding sepsis and is not the appropriate classification here.
From a CDI perspective, the defining feature is not simply that the patient is critically ill. It is the documented relationship between sepsis and acute organ dysfunction.
CCDS Reference Topics: Sepsis; severe sepsis; acute organ dysfunction; sequencing guidelines.
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NEW QUESTION # 129
A patient's record contains fever, tachycardia, hypotension, positive blood cultures, and treatment with IV antibiotics and fluids. No corresponding diagnosis has been documented. Which query format is MOST appropriate?
Answer: D
Explanation:
A neutral multiple-choice query is appropriate when significant clinical indicators exist but no corresponding diagnosis has been documented. The query should present the relevant patient-specific facts and allow the provider to exercise independent clinical judgment among reasonable alternatives.
For example, depending on the complete record, options could include sepsis, localized infection without sepsis, bacteremia, another condition, or unable to determine. Each offered diagnosis must be clinically supported.
A yes/no query is generally inappropriate when it introduces a completely new diagnosis that has never appeared in the health record. Option B is overtly leading because it directs the provider to document sepsis rather than requesting clarification.
The 2026 ACDIS/AHIMA compliant-query guidance, published August 20, 2026, supersedes all previous versions and serves as the current foundational standard for CDI and coding query practice. It applies across inpatient, outpatient, ambulatory, and professional-fee settings.
The purpose of the query is documentation integrity-not obtaining an MCC, changing the MS-DRG, or achieving a particular quality result.
CCDS Reference Topics: Multiple-choice queries; missing diagnosis; nonleading queries; clinical indicators; compliance.
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NEW QUESTION # 130
A patient with severe cachexia and substantial loss of appetite requires pharmacologic treatment to stimulate appetite. Which of the following medications is most commonly associated with this indication?
Answer: B
Explanation:
Megestrol acetate is the correct choice. This item is adapted from an official ACDIS CCDS sample question in the Candidate Handbook, where Megace-megestrol acetate-is identified as the appropriate appetite- stimulating medication.
Megestrol acetate is a synthetic progestational agent with recognized appetite-stimulating effects. Current U.
S. prescribing information specifically identifies megestrol acetate oral suspension for anorexia, cachexia, or significant unexplained weight loss in patients with AIDS. Its use illustrates why CDI specialists need functional knowledge of pharmacology: medication profiles can provide clinically relevant clues to diagnoses under evaluation, although a medication alone never establishes a reportable diagnosis.
Memantine is primarily used in Alzheimer's disease and is not an appetite stimulant. Levothyroxine replaces thyroid hormone in hypothyroidism. Sibutramine was historically used for weight reduction rather than cachexia and is therefore directionally opposite to the desired effect.
In CDI review, identification of megestrol may prompt assessment of the record for malnutrition, cachexia, malignancy-related weight loss, HIV-associated wasting, or another underlying cause, but the provider must document the diagnosis.
CCDS Reference Topics: Pharmacology; cachexia; nutrition disorders; clinical indicators.
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NEW QUESTION # 131
The progress note on hospital day 2 of a patient's admission states that the patient got up from the bed to go to the bathroom just after housekeeping had mopped the floor. The patient slipped and fell onto the floor, sustaining a broken wrist. The diagnosis of a fractured wrist will:
Answer: D
Explanation:
The fracture occurred after inpatient admission as the result of a hospital fall, placing it within CMS's Hospital-Acquired Condition category for Falls and Trauma when the applicable fracture code is included in the HAC code list. CMS's FY 2026 MS-DRG Definitions Manual continues to identify qualifying fracture codes within HAC 05.
The fracture must still be coded; therefore, option D is incorrect. Because it clearly developed after admission, it would not appropriately receive POA indicator "U," which indicates insufficient documentation to determine whether the condition was present on admission.
For qualifying HAC diagnoses that are not POA, CMS payment logic prevents the hospital from receiving the higher MS-DRG payment that would otherwise result solely from the condition's CC/MCC status. Thus, option B expresses the intended payment effect.
This distinction is central to CDI practice: a hospital-acquired diagnosis does not disappear from the record or coding. It remains reportable for clinical and quality purposes, but certain qualifying HACs are treated differently in MS-DRG payment calculations.
CCDS Reference Topics: HACs; POA indicators; Falls and Trauma; MS-DRG payment adjustment.
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NEW QUESTION # 132
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