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| Section | Weight | Objectives |
|---|---|---|
| Topic 1: Healthcare facility CDI program analysis | 8.33% | - Publicly reported data - Patient Safety Indicators - CC/MCC capture - Severity of illness and risk of mortality - Case mix index (CMI) - Physician performance measurement - Hospital Value-Based Purchasing measures - Provider response rates - CDI specialist productivity metrics - High-frequency DRGs - PEPPER data - Tracking and trending physician, department, and hospital performance - Hospital-specific financial data - Basic computer and software application skills - CDI program forecasting |
| Topic 2: Impact of reportable diagnoses on quality of care | 8.33% | - Patient Safety Indicators - Hospital Inpatient Quality Reporting Program - Quality data from record abstraction and claims data - Coded data elements affecting Patient Safety Indicators - CDI impact on Hospital Value-Based Purchasing - Hospital Readmissions Reduction Program - Documentation and code assignment impact on mortality index - Healthcare-associated infections and complication codes - Hospital Value-Based Purchasing - 30-day mortality measures - Hospital-Acquired Condition Reduction Program - Mortality reviews and observed/expected ratios |
| Topic 3: Medical record documentation | 19.17% | - Provider role and diagnosis code assignment - Addressing diagnoses without clinical support - Situations in which queries are not appropriate - Clinical indicators - Health record elements used for diagnosis and procedure code assignment - ACDIS/AHIMA Guidelines for Achieving a Compliant Query Practice - Documentation requiring clarification - When a physician query is warranted - Translating clinical indicators into compliant queries - Types of physician queries - Physician query formats - Compliant and noncompliant queries |
| Topic 4: Official Guidelines for Coding and Reporting | 14.17% | - Principal diagnosis assignment - Present on admission indicators - Hospital-acquired conditions - Coding guidelines for principal diagnosis selection - Working DRG assignment for multiple diagnoses - Official Guidelines for Coding and Reporting updates - AHA Coding Clinic - Secondary diagnosis assignment - Discharge dispositions and transfers |
| Topic 5: Healthcare regulations, reimbursement, and documentation requirements related to the IPPS | 12.5% | - Major complication/comorbidity (MCC) - Inpatient admission criteria and CMS Two-Midnight Rule - IPPS and its updates and revisions - Documentation and medical necessity of setting - Medical staff and clinical staff documentation responsibilities - Medicare Severity Diagnosis Related Groups (MS-DRGs) - Case mix index (CMI) - Principal diagnosis and medical necessity - Coding and billing practices vulnerable to denial - Complication/comorbidity (CC) - Medicare contractors and their impact on CDI - Documentation impact on IPPS reimbursement |
| Topic 6: Communication skills | 9.17% | - Roles and responsibilities of coders working with CDI departments - Effective and non-confrontational physician communication - Roles and responsibilities of CDI specialists - Verbal versus written physician communication - Educational presentations for healthcare departments and administration - Reconciling CDI working DRGs with final coded DRGs - Physician education forms and tools |
| Topic 7: Anatomy and physiology, pathophysiology, pharmacology, and medical terminology | 19.17% | - Clinical indicators and query opportunities by Major Diagnostic Category - Diseases and disorders of the digestive system - Diseases and disorders of the hepatobiliary system - Diseases and disorders of the respiratory system - Injuries, poisonings, and toxic effects of drugs - HIV infections - Diseases and disorders of the skin, subcutaneous tissue, and breast - Diseases and disorders of the blood and blood-forming organs and immunological disorders - Diseases and disorders of the nervous system - Mental diseases and disorders - Standard medical abbreviations - Diseases and disorders of the musculoskeletal system - Myeloproliferative diseases and disorders and poorly differentiated neoplasms - Infectious and parasitic diseases - Diseases and disorders of the circulatory system - Diagnostic tests as clinical indicators - Pharmaceuticals and disease processes - Alcohol/drug use and alcohol/drug-induced organic brain disorders - Endocrine, nutritional, and metabolic diseases and disorders - Diseases and disorders of the kidney and urinary tract - Medications as clinical indicators |
| Topic 8: Professionalism, ethics, and compliance | 9.17% | - CDI department goals beyond reimbursement - DRG compliance initiatives - Compliance risks indicated by PEPPER - Leading queries - Medical record confidentiality - Potential DRG creep |
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NEW QUESTION # 32
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: A
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 # 33
A patient experienced a type 1 STEMI 10 days ago. The patient is readmitted and develops a new type 1 NSTEMI during the four-week acute myocardial infarction period. Which ICD-10-CM concept applies?
Answer: A
Explanation:
ICD-10-CM provides category I22 for a subsequent acute myocardial infarction occurring within four weeks-28 days-of an initial acute MI, when the qualifying MI types and circumstances meet the classification requirements.
The FY 2026 Official Guidelines specify that when a patient with a type 1 or unspecified acute MI experiences a new type 1 or unspecified MI within four weeks of the initial MI, a code from category I22 is used together with the appropriate I21 code. Sequencing depends on the circumstances of the encounter.
This rule requires care because type 2 MI and certain other myocardial infarction classifications do not follow the same I22 subsequent-MI logic. CDI specialists therefore need accurate documentation of MI type, anatomic location when applicable, timing, and whether the current event represents a genuinely new infarction rather than ongoing care for the original MI.
The prior STEMI does not become an "old MI" merely because the patient left the hospital; the ICD-10-CM acute MI period extends for four weeks from onset.
CCDS Reference Topics: Acute MI; subsequent MI; I21/I22; four-week rule; cardiovascular coding.
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NEW QUESTION # 34
A patient is admitted with pneumonia. On hospital day 3, the patient deteriorates and the physician documents that sepsis developed after admission as a consequence of the pneumonia. Which diagnosis is generally sequenced first?
Answer: A
Explanation:
When a patient is admitted with a localized infection and sepsis develops after admission, the localized infection is generally sequenced as the principal diagnosis, followed by the appropriate sepsis code.
The FY 2026 ICD-10-CM Official Guidelines explicitly distinguish this circumstance from cases in which both the localized infection and sepsis are present on admission. When sepsis develops only after admission, the localized infection responsible for the original hospitalization remains principal.
Therefore, pneumonia is sequenced first in this scenario.
If the patient subsequently develops acute organ dysfunction related to sepsis and the provider documents severe sepsis, additional severe-sepsis and organ-dysfunction codes are assigned as appropriate. The severe- sepsis code cannot itself serve as principal diagnosis.
This question demonstrates why CDI specialists must clarify timing. Simply seeing both "pneumonia" and
"sepsis" in a discharge summary is insufficient to determine correct sequencing when the onset relationship is unclear.
The POA status of sepsis also becomes relevant because documentation indicates that it developed after inpatient admission.
CCDS Reference Topics: Sepsis; pneumonia; sequencing; timing; POA; principal diagnosis.
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NEW QUESTION # 35
For FY 2026 Hospital Value-Based Purchasing, each of the four scored domains generally contributes what percentage to the Total Performance Score when all four domains are scored?
Answer: C
Explanation:
When all four Hospital VBP domains are scored, each domain contributes 25% of the hospital's Total Performance Score.
For FY 2026, the four domains are Clinical Outcomes, Person and Community Engagement, Safety, and Efficiency and Cost Reduction. CMS's Provider Data Catalog confirms that each contributes one-quarter of the Total Performance Score under the standard four-domain configuration.
The Clinical Outcomes domain includes mortality and complication measures. Person and Community Engagement incorporates HCAHPS patient-experience dimensions. The Safety domain contains healthcare- associated infection and safety-related measures, while Efficiency and Cost Reduction incorporates Medicare spending measures.
If a hospital receives valid scores in only three domains, CMS proportionately reweights the scored domains rather than simply assigning zero to the missing domain.
For CCDS practice, understanding these domains helps explain why accurate documentation influences more than MS-DRG reimbursement. Clinical documentation can affect severity adjustment, complications analysis, mortality calculations, and the reliability of administrative data used in performance measurement.
CCDS Reference Topics: Hospital VBP; Total Performance Score; quality domains; risk adjustment; hospital performance.
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NEW QUESTION # 36
A CDI specialist reviews the MS-DRG mismatch report and notes a difference in a case. The coder noted that a current Coding Clinic affects the final coding of the record, which changed the MS-DRG assignment. To BEST understand this discrepancy, the specialist should FIRST:
Answer: B
Explanation:
The CDI specialist should first review the final coded record together with the Coding Clinic guidance identified by the coder. This provides an objective basis for understanding why the final MS-DRG differs from the CDI working DRG.
A mismatch does not automatically indicate that either CDI or coding made an error. Working DRGs are provisional and may change after complete review of discharge documentation, operative reports, pathology, final diagnostic information, coding conventions, official guidelines, or authoritative Coding Clinic advice.
Reviewing the applicable guidance before contacting the coder promotes an informed and efficient reconciliation process. Once the specialist understands the coding rule, discussion with the coder may still be useful if ambiguity remains. Immediately escalating to the coding manager is unnecessary unless the issue cannot be resolved through normal collaboration. Forwarding the record without investigating the mismatch would defeat the purpose of a reconciliation process and could allow recurring education opportunities to remain unidentified.
Mismatch analysis is a valuable CDI quality metric because it can identify documentation gaps, coding- knowledge issues, changes in authoritative guidance, and opportunities to improve CDI/coding alignment.
CCDS Reference Topics: MS-DRG reconciliation; CDI/coder collaboration; Coding Clinic application; CDI program analysis.
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NEW QUESTION # 37
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