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| Section | Weight | Objectives |
|---|---|---|
| Topic 1: Official Guidelines for Coding and Reporting | 14.17% | - AHA Coding Clinic - Official Guidelines for Coding and Reporting updates - Principal diagnosis assignment - Discharge dispositions and transfers - Coding guidelines for principal diagnosis selection - Secondary diagnosis assignment - Working DRG assignment for multiple diagnoses - Hospital-acquired conditions - Present on admission indicators |
| Topic 2: Anatomy and physiology, pathophysiology, pharmacology, and medical terminology | 19.17% | - Standard medical abbreviations - Diseases and disorders of the hepatobiliary system - Diseases and disorders of the kidney and urinary tract - Alcohol/drug use and alcohol/drug-induced organic brain disorders - Endocrine, nutritional, and metabolic diseases and disorders - Injuries, poisonings, and toxic effects of drugs - Mental diseases and disorders - Myeloproliferative diseases and disorders and poorly differentiated neoplasms - Infectious and parasitic diseases - Diseases and disorders of the respiratory system - Diseases and disorders of the blood and blood-forming organs and immunological disorders - Diseases and disorders of the digestive system - HIV infections - Diagnostic tests as clinical indicators - Diseases and disorders of the skin, subcutaneous tissue, and breast - Clinical indicators and query opportunities by Major Diagnostic Category - Medications as clinical indicators - Diseases and disorders of the circulatory system - Diseases and disorders of the musculoskeletal system - Pharmaceuticals and disease processes - Diseases and disorders of the nervous system |
| Topic 3: Professionalism, ethics, and compliance | 9.17% | - Medical record confidentiality - CDI department goals beyond reimbursement - Potential DRG creep - Compliance risks indicated by PEPPER - Leading queries - DRG compliance initiatives |
| Topic 4: Healthcare facility CDI program analysis | 8.33% | - Case mix index (CMI) - Publicly reported data - Hospital-specific financial data - PEPPER data - Tracking and trending physician, department, and hospital performance - Basic computer and software application skills - CDI program forecasting - CC/MCC capture - CDI specialist productivity metrics - Patient Safety Indicators - High-frequency DRGs - Physician performance measurement - Severity of illness and risk of mortality - Hospital Value-Based Purchasing measures - Provider response rates |
| Topic 5: Communication skills | 9.17% | - Physician education forms and tools - Roles and responsibilities of CDI specialists - Educational presentations for healthcare departments and administration - Roles and responsibilities of coders working with CDI departments - Verbal versus written physician communication - Effective and non-confrontational physician communication - Reconciling CDI working DRGs with final coded DRGs |
| Topic 6: Healthcare regulations, reimbursement, and documentation requirements related to the IPPS | 12.5% | - Case mix index (CMI) - Inpatient admission criteria and CMS Two-Midnight Rule - Documentation and medical necessity of setting - IPPS and its updates and revisions - Documentation impact on IPPS reimbursement - Principal diagnosis and medical necessity - Major complication/comorbidity (MCC) - Complication/comorbidity (CC) - Medicare Severity Diagnosis Related Groups (MS-DRGs) - Medicare contractors and their impact on CDI - Coding and billing practices vulnerable to denial - Medical staff and clinical staff documentation responsibilities |
| Topic 7: Medical record documentation | 19.17% | - When a physician query is warranted - Physician query formats - Compliant and noncompliant queries - Types of physician queries - Documentation requiring clarification - Translating clinical indicators into compliant queries - Provider role and diagnosis code assignment - Health record elements used for diagnosis and procedure code assignment - ACDIS/AHIMA Guidelines for Achieving a Compliant Query Practice - Addressing diagnoses without clinical support - Clinical indicators - Situations in which queries are not appropriate |
| Topic 8: Impact of reportable diagnoses on quality of care | 8.33% | - 30-day mortality measures - Mortality reviews and observed/expected ratios - Hospital Readmissions Reduction Program - Documentation and code assignment impact on mortality index - Healthcare-associated infections and complication codes - CDI impact on Hospital Value-Based Purchasing - Hospital-Acquired Condition Reduction Program - Hospital Value-Based Purchasing - Hospital Inpatient Quality Reporting Program - Coded data elements affecting Patient Safety Indicators - Patient Safety Indicators - Quality data from record abstraction and claims data |
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NEW QUESTION # 75
A hospital has a total MS-DRG relative weight of 2,640 for 1,600 inpatient discharges. What is its case mix index?
Answer: C
Explanation:
Case mix index is calculated by dividing the sum of MS-DRG relative weights by the number of inpatient discharges:
2,640 ÷ 1,600 = 1.65
Therefore, the CMI is 1.65.
CMI represents the average relative resource intensity of the hospital's inpatient cases. It is affected by the types of patients treated, surgical versus medical mix, tertiary services, transplant or trauma volume, documentation specificity, coding accuracy, and annual changes to MS-DRG relative weights and grouper logic.
CMS publishes hospital case-mix information and FY 2026 relative weighting factors through the IPPS Final Rule supporting data. Table 5 contains MS-DRGs and relative weighting factors, while Table 2 contains hospital-specific case-mix information.
A decline in CMI should not automatically be interpreted as a CDI failure. A shift toward lower-complexity cases or changes in service lines can legitimately reduce CMI even with excellent documentation.
CDI managers should therefore trend CMI alongside diagnosis capture, surgical volume, service lines, payer population, coding reconciliation, and quality indicators.
CCDS Reference Topics: Case mix index; MS-DRG relative weight; CDI analytics; hospital performance.
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NEW QUESTION # 76
Documentation indicates an excisional debridement was performed without further specification. The CDI specialist should query to clarify which of the following?
Answer: C
Explanation:
The most critical missing element is the depth or level of tissue actually debrided. Documentation of an excisional debridement should identify whether tissue removed included skin, subcutaneous tissue, fascia, muscle, bone, or another anatomical layer. The level removed is fundamental to accurate procedural classification and coding.
CMS wound-care documentation standards similarly emphasize that the medical record should describe the type and depth of tissue removed. Merely knowing that an excisional debridement occurred does not establish the anatomical level of the procedure.
The instrument may provide useful procedural context-for example, scalpel, scissors, curette, or other technique-but the instrument alone does not identify the deepest tissue excised. Wound size can be important for clinical care and certain coding systems, but it does not replace documentation of the tissue level removed. The identity of the person performing the procedure is also part of procedural documentation but does not answer the principal coding-specific deficiency in this scenario.
A CDI query should therefore seek the deepest tissue level actually excised rather than infer it from the wound's overall depth.
CCDS Reference Topics: Medical record documentation; ICD-10-PCS/procedure documentation; debridement specificity.
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NEW QUESTION # 77
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?
Answer: A
Explanation:
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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NEW QUESTION # 78
A patient with dysphagia after a recent stroke develops fever, hypoxia, and a right lower-lobe infiltrate. The physician documents "pneumonia." Speech therapy documents repeated aspiration with oral intake. What is the MOST appropriate CDI action?
Answer: B
Explanation:
The record presents a legitimate opportunity to clarify the type or etiology of pneumonia, particularly whether aspiration contributed to the pulmonary infection. Dysphagia following stroke, documented aspiration during oral intake, fever, hypoxia, and a dependent-lobe infiltrate form a clinically relevant pattern.
However, the CDI specialist cannot independently convert unspecified pneumonia into aspiration pneumonia.
Likewise, the speech-language pathologist can provide valuable clinical evidence regarding swallowing dysfunction and aspiration risk, but that documentation does not independently establish the medical diagnosis of aspiration pneumonia for coding purposes.
A compliant query should objectively present the pertinent indicators and allow the provider to identify aspiration pneumonia, another pneumonia type, pneumonitis, another condition, or inability to determine.
Automatically assigning both bacterial and aspiration pneumonia would also be inappropriate because neither bacterial etiology nor a separate second pneumonia diagnosis has been established.
The current ACDIS/AHIMA guidance emphasizes that queries should arise from the clinical record and preserve the provider's independent judgment rather than directing a preferred diagnosis.
CCDS Reference Topics: Pneumonia specificity; aspiration; dysphagia; interdisciplinary documentation; compliant query development.
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NEW QUESTION # 79
A pregnant female presents to the ED with diarrhea, cramps, nausea, and vomiting for the past 12 hours. She was admitted with enteritis due to Clostridium difficile and provided IV fluids. Which of the following coding guidelines applies to determining the principal diagnosis for this patient?
Answer: A
Explanation:
For a pregnant patient, the first coding consideration is the Chapter 15 obstetric guideline unless the provider explicitly documents that the pregnancy is incidental to the encounter. ICD-10-CM codes from O00-O9A have sequencing priority over codes from other chapters when a condition complicates pregnancy, childbirth, or the puerperium.
Therefore, although the patient's underlying clinical disease is Clostridium difficile enteritis, the principal- diagnosis analysis begins with the applicable pregnancy-complication code. An additional infectious-disease code would then be used as appropriate to identify the specific infection. The infectious and parasitic disease chapter does not override the obstetric sequencing rules.
Signs such as diarrhea, cramps, nausea, and vomiting are also not the principal coding focus once a definitive diagnosis-C. difficile enteritis-has been established. Similarly, an etiology/manifestation sequencing convention is not the controlling rule in this scenario.
The critical CCDS concept is recognition of chapter-specific sequencing rules. A CDI specialist reviewing pregnant patients must recognize that otherwise standard principal-diagnosis logic may be superseded by obstetric instructions.
CCDS Reference Topics: Official Guidelines for Coding and Reporting-Chapter 15; principal diagnosis selection; chapter-specific sequencing.
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NEW QUESTION # 80
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