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| Section | Weight | Objectives |
|---|---|---|
| Healthcare facility CDI program analysis | 8.33% | - Provider response rates - Case mix index (CMI) - High-frequency DRGs - CDI specialist productivity metrics - Hospital-specific financial data - Physician performance measurement - Patient Safety Indicators - Hospital Value-Based Purchasing measures - PEPPER data - CDI program forecasting - Publicly reported data - CC/MCC capture - Tracking and trending physician, department, and hospital performance - Basic computer and software application skills - Severity of illness and risk of mortality |
| Communication skills | 9.17% | - Educational presentations for healthcare departments and administration - Roles and responsibilities of CDI specialists - Effective and non-confrontational physician communication - Roles and responsibilities of coders working with CDI departments - Verbal versus written physician communication - Physician education forms and tools - Reconciling CDI working DRGs with final coded DRGs |
| Impact of reportable diagnoses on quality of care | 8.33% | - Quality data from record abstraction and claims data - Hospital-Acquired Condition Reduction Program - Hospital Readmissions Reduction Program - Mortality reviews and observed/expected ratios - 30-day mortality measures - Patient Safety Indicators - CDI impact on Hospital Value-Based Purchasing - Coded data elements affecting Patient Safety Indicators - Healthcare-associated infections and complication codes - Hospital Inpatient Quality Reporting Program - Hospital Value-Based Purchasing - Documentation and code assignment impact on mortality index |
| Anatomy and physiology, pathophysiology, pharmacology, and medical terminology | 19.17% | - Diseases and disorders of the skin, subcutaneous tissue, and breast - Diseases and disorders of the hepatobiliary system - Diseases and disorders of the kidney and urinary tract - HIV infections - Infectious and parasitic diseases - Diagnostic tests as clinical indicators - Myeloproliferative diseases and disorders and poorly differentiated neoplasms - Standard medical abbreviations - Medications as clinical indicators - Alcohol/drug use and alcohol/drug-induced organic brain disorders - Clinical indicators and query opportunities by Major Diagnostic Category - Diseases and disorders of the respiratory system - Injuries, poisonings, and toxic effects of drugs - Mental diseases and disorders - Diseases and disorders of the circulatory system - Diseases and disorders of the musculoskeletal system - Diseases and disorders of the blood and blood-forming organs and immunological disorders - Pharmaceuticals and disease processes - Diseases and disorders of the nervous system - Diseases and disorders of the digestive system - Endocrine, nutritional, and metabolic diseases and disorders |
| Professionalism, ethics, and compliance | 9.17% | - Compliance risks indicated by PEPPER - DRG compliance initiatives - CDI department goals beyond reimbursement - Potential DRG creep - Medical record confidentiality - Leading queries |
| Healthcare regulations, reimbursement, and documentation requirements related to the IPPS | 12.5% | - Major complication/comorbidity (MCC) - Case mix index (CMI) - Principal diagnosis and medical necessity - Inpatient admission criteria and CMS Two-Midnight Rule - Coding and billing practices vulnerable to denial - Medicare contractors and their impact on CDI - Complication/comorbidity (CC) - Medicare Severity Diagnosis Related Groups (MS-DRGs) - Documentation impact on IPPS reimbursement - Documentation and medical necessity of setting - Medical staff and clinical staff documentation responsibilities - IPPS and its updates and revisions |
| Official Guidelines for Coding and Reporting | 14.17% | - Working DRG assignment for multiple diagnoses - Present on admission indicators - Discharge dispositions and transfers - Hospital-acquired conditions - AHA Coding Clinic - Principal diagnosis assignment - Official Guidelines for Coding and Reporting updates - Secondary diagnosis assignment - Coding guidelines for principal diagnosis selection |
| Medical record documentation | 19.17% | - Health record elements used for diagnosis and procedure code assignment - Types of physician queries - ACDIS/AHIMA Guidelines for Achieving a Compliant Query Practice - When a physician query is warranted - Clinical indicators - Situations in which queries are not appropriate - Documentation requiring clarification - Translating clinical indicators into compliant queries - Physician query formats - Addressing diagnoses without clinical support - Provider role and diagnosis code assignment - Compliant and noncompliant queries |
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NEW QUESTION # 101
A CDI program is developing a query escalation policy. A clinically significant query remains unanswered despite normal reminders. Which action is MOST appropriate?
Answer: B
Explanation:
An unanswered clinically significant query should be managed through the organization's defined escalation process. The process may involve CDI leadership, coding leadership, a physician advisor, department leadership, or other designated personnel, depending on organizational policy.
Neither CDI nor coding may independently supply the missing diagnosis because diagnostic conclusions remain the provider's responsibility. Removing an unresolved query simply to accelerate billing can undermine documentation integrity and may create compliance problems.
Escalation policies should be standardized rather than applied only when a particular diagnosis affects reimbursement. Policies commonly address expected response time, reminder intervals, responsible escalation personnel, high-priority queries, retrospective queries, and final-bill procedures.
The 2026 ACDIS/AHIMA Guidelines for Achieving a Compliant Query Practice supersede prior versions and serve as the current foundational guidance for organizations establishing compliant query policies and procedures.
A mature escalation process balances timely claim completion with respect for provider workload and independent clinical judgment. Its purpose is obtaining complete and accurate documentation, not forcing agreement with a CDI-generated diagnosis.
CCDS Reference Topics: Query escalation; organizational policy; unanswered queries; compliance; provider responsibility.
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NEW QUESTION # 102
A patient is admitted with fever and weakness. On hospital day 3, final blood cultures identify an infection that the physician documents was present at the time of admission. Which statement about present-on- admission status is MOST accurate?
Answer: D
Explanation:
A condition can be assigned present-on-admission status even when the definitive diagnosis is not made until later in the hospitalization. POA refers to whether the condition was present at the time the order for inpatient admission occurred, not the calendar date on which diagnostic confirmation became available.
This distinction is particularly relevant for infections, malignancies, fractures, acute vascular events, and other conditions whose definitive identification may require cultures, pathology, imaging, or additional diagnostic testing.
Therefore, a blood culture finalized on hospital day 3 does not automatically make the infection hospital acquired. The clinical record and provider documentation must establish whether the disease process was present at admission.
POA assignment applies to applicable principal and secondary diagnoses, not only the principal diagnosis.
CDI specialists should recognize unclear timing as a potential clarification opportunity because POA status can affect CMS Hospital-Acquired Condition payment logic and quality reporting.
The CCDS content outline expressly includes the basics of POA assignment and its impact on payment, as well as identification of CMS HACs.
CCDS Reference Topics: Present on admission; diagnosis timing; HACs; inpatient coding; quality reporting.
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NEW QUESTION # 103
Two diagnoses both meet the definition of principal diagnosis and either could appropriately be sequenced first under the circumstances of admission. No specific sequencing instruction directs otherwise. Which rule applies?
Answer: C
Explanation:
When two diagnoses equally meet the definition of principal diagnosis, either condition may be sequenced first when the circumstances of admission, diagnostic workup, and treatment equally support both and no specific coding guideline, tabular instruction, or other sequencing rule directs otherwise.
The principal diagnosis cannot be selected based on which option generates higher payment. Financial outcome is not a legitimate sequencing criterion.
Likewise, chronological age of the diagnosis does not determine principal-diagnosis status. The principal diagnosis is established after study as the condition chiefly responsible for occasioning the admission.
A CDI query may be appropriate when the documentation does not actually establish whether both diagnoses equally occasioned the admission. However, querying simply because one sequencing choice would produce a more favorable MS-DRG is inappropriate.
This scenario tests the distinction between valid coding flexibility and improper reimbursement-driven documentation practices. CDI professionals must understand coding conventions well enough to avoid unnecessary queries while recognizing genuine ambiguity that requires provider clarification.
The FY 2026 MS-DRG grouper and Definitions Manual published by CMS provide the applicable grouper logic for the current fiscal year.
CCDS Reference Topics: Principal diagnosis; equally qualifying diagnoses; sequencing; ethical reimbursement practice.
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NEW QUESTION # 104
An MS-DRG family is divided into three severity levels: with MCC, with CC, and without CC/MCC.
Assuming all other grouper conditions are identical, which secondary diagnosis category generally results in the highest severity-level assignment?
Answer: C
Explanation:
An MCC-major complication or comorbidity-represents the highest secondary-diagnosis severity category within the standard three-tier MS-DRG hierarchy. CMS describes MCCs as diagnoses with the highest level of severity affecting hospital resource use, CCs as conditions with a moderate level, and non-CC diagnoses as the lowest severity level.
When an MS-DRG family is divided into "with MCC," "with CC," and "without CC/MCC," the presence of a qualifying MCC generally moves the case into the highest severity subdivision, assuming no exclusion or other grouper rule prevents that effect.
This does not mean every MCC always increases payment. Some secondary diagnoses are excluded as MCCs or CCs in particular circumstances because of principal-diagnosis exclusions or DRG-specific logic. CMS's FY 2026 Definitions Manual specifically contains exclusion lists and severity logic for such situations.
CDI specialists should understand MCC/CC logic to interpret working DRGs, but query activity must be driven by clinical accuracy rather than the financial value of a severity level.
CCDS Reference Topics: MS-DRGs; MCC; CC; severity subdivisions; resource utilization; reimbursement compliance.
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NEW QUESTION # 105
A physician documents acute kidney injury. The patient's creatinine is 0.8 mg/dL on admission, 0.9 mg/dL the following day, and 0.8 mg/dL at discharge. Urine output remains normal and no renal treatment is provided.
What is the BEST CDI action?
Answer: D
Explanation:
A clinical validation query is appropriate because the documented diagnosis appears inconsistent with the available clinical evidence. The creatinine values remain essentially unchanged, urine output is normal, and there is no apparent treatment or monitoring consistent with acute renal dysfunction.
The CDI specialist cannot simply delete the diagnosis because providers are responsible for establishing diagnoses. Conversely, a diagnosis should not automatically be accepted when substantial clinical evidence raises a legitimate question about its validity.
A compliant query would present the documented AKI together with the pertinent renal findings and request clarification. The provider could confirm AKI and provide supporting clinical reasoning, revise the diagnosis, state that it was ruled out, or document another condition.
Assigning chronic kidney disease would be equally inappropriate because CKD requires evidence of chronic kidney abnormality and cannot be inferred from these laboratory values.
The August 2026 ACDIS/AHIMA query guidance supersedes prior versions and remains the foundational standard for clinical validation and documentation clarification.
Clinical validation protects data integrity because diagnoses influence reimbursement, quality reporting, severity measurement, utilization analysis, and downstream patient information.
CCDS Reference Topics: Clinical validation; AKI; unsupported diagnoses; provider clarification; compliance.
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NEW QUESTION # 106
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