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| Section | Weight | Objectives |
|---|---|---|
| Official Guidelines for Coding and Reporting | 14.17% | - Secondary diagnosis assignment - Hospital-acquired conditions - Official Guidelines for Coding and Reporting updates - Coding guidelines for principal diagnosis selection - AHA Coding Clinic - Present on admission indicators - Discharge dispositions and transfers - Working DRG assignment for multiple diagnoses - Principal diagnosis assignment |
| Professionalism, ethics, and compliance | 9.17% | - Compliance risks indicated by PEPPER - Medical record confidentiality - CDI department goals beyond reimbursement - Potential DRG creep - DRG compliance initiatives - Leading queries |
| Healthcare facility CDI program analysis | 8.33% | - CDI program forecasting - Provider response rates - High-frequency DRGs - Basic computer and software application skills - CDI specialist productivity metrics - PEPPER data - Hospital Value-Based Purchasing measures - Severity of illness and risk of mortality - Physician performance measurement - Patient Safety Indicators - CC/MCC capture - Hospital-specific financial data - Publicly reported data - Case mix index (CMI) - Tracking and trending physician, department, and hospital performance |
| Impact of reportable diagnoses on quality of care | 8.33% | - Hospital-Acquired Condition Reduction Program - Quality data from record abstraction and claims data - Documentation and code assignment impact on mortality index - Healthcare-associated infections and complication codes - Coded data elements affecting Patient Safety Indicators - 30-day mortality measures - Patient Safety Indicators - Mortality reviews and observed/expected ratios - CDI impact on Hospital Value-Based Purchasing - Hospital Inpatient Quality Reporting Program - Hospital Value-Based Purchasing - Hospital Readmissions Reduction Program |
| Medical record documentation | 19.17% | - Physician query formats - Situations in which queries are not appropriate - Compliant and noncompliant queries - Addressing diagnoses without clinical support - When a physician query is warranted - Clinical indicators - Provider role and diagnosis code assignment - Translating clinical indicators into compliant queries - Types of physician queries - Documentation requiring clarification - ACDIS/AHIMA Guidelines for Achieving a Compliant Query Practice - Health record elements used for diagnosis and procedure code assignment |
| Healthcare regulations, reimbursement, and documentation requirements related to the IPPS | 12.5% | - Inpatient admission criteria and CMS Two-Midnight Rule - Complication/comorbidity (CC) - Major complication/comorbidity (MCC) - Medical staff and clinical staff documentation responsibilities - IPPS and its updates and revisions - Principal diagnosis and medical necessity - Documentation impact on IPPS reimbursement - Documentation and medical necessity of setting - Medicare contractors and their impact on CDI - Medicare Severity Diagnosis Related Groups (MS-DRGs) - Coding and billing practices vulnerable to denial - Case mix index (CMI) |
| Anatomy and physiology, pathophysiology, pharmacology, and medical terminology | 19.17% | - Standard medical abbreviations - Diseases and disorders of the blood and blood-forming organs and immunological disorders - Diseases and disorders of the respiratory system - Diagnostic tests as clinical indicators - Diseases and disorders of the kidney and urinary tract - Diseases and disorders of the skin, subcutaneous tissue, and breast - Diseases and disorders of the digestive system - Alcohol/drug use and alcohol/drug-induced organic brain disorders - HIV infections - Pharmaceuticals and disease processes - Medications as clinical indicators - Endocrine, nutritional, and metabolic diseases and disorders - Mental diseases and disorders - Clinical indicators and query opportunities by Major Diagnostic Category - Myeloproliferative diseases and disorders and poorly differentiated neoplasms - Diseases and disorders of the circulatory system - Injuries, poisonings, and toxic effects of drugs - Infectious and parasitic diseases - Diseases and disorders of the nervous system - Diseases and disorders of the musculoskeletal system - Diseases and disorders of the hepatobiliary system |
| Communication skills | 9.17% | - Reconciling CDI working DRGs with final coded DRGs - Roles and responsibilities of coders working with CDI departments - Effective and non-confrontational physician communication - Educational presentations for healthcare departments and administration - Physician education forms and tools - Roles and responsibilities of CDI specialists - Verbal versus written physician communication |
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NEW QUESTION # 80
A physician responds to a clinically supported CDI query by stating that the proposed diagnosis does not apply and documents a different diagnosis supported by the patient's condition. What is the BEST action by the CDI specialist?
Answer: C
Explanation:
The CDI specialist should respect the provider's independent clinical judgment, provided the response clearly addresses the query and the resulting documentation is clinically coherent.
A query is a request for clarification-not a mechanism for compelling the provider to select CDI's preferred diagnosis. Physician disagreement is therefore not inherently a failed query. The provider may appropriately document another condition, rule out a suspected condition, or explain why the indicators have another clinical interpretation.
Repeatedly querying until a desired diagnosis appears creates serious compliance risk and can undermine the integrity of the documentation process. Escalation may be appropriate in defined circumstances-for example, unresolved contradictions, unanswered high-priority queries, or persistent clinical-validation issues-but should follow organizational policy and should not occur merely because CDI dislikes the provider's answer.
The 2026 ACDIS/AHIMA guidance is the current foundational query-practice standard and emphasizes compliant clarification across healthcare settings.
Effective CDI communication requires clinical knowledge, professional dialogue, and recognition that final diagnostic determinations belong to the responsible provider.
CCDS Reference Topics: Physician communication; query responses; provider independence; escalation; professional conduct.
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NEW QUESTION # 81
A hospital's case is assigned to an MS-DRG with a relative weight of 2.0000. What does the relative weight primarily indicate?
Answer: B
Explanation:
An MS-DRG relative weight represents relative expected resource consumption, not a direct severity score or mortality probability. Therefore, a relative weight of approximately 2.0 means the MS-DRG is associated with roughly twice the resource intensity of the average case represented by the standardized reference point.
CMS calculates and recalibrates MS-DRG relative weights using national hospital data as part of IPPS rate setting. The FY 2026 final-rule materials include the MS-DRG weighting factors as well as supporting cost data used in the relative-weight methodology.
Clinically complex cases often consume more resources, so relative weight may correlate with severity.
However, it is not equivalent to a patient's severity-of-illness score or risk-of-mortality score. Likewise, hospitals do not simply multiply their billed charges based on the DRG weight. IPPS payment involves the standardized amount plus various adjustments, including wage index and other applicable payment factors.
For CDI, accurate documentation matters because diagnoses and procedures drive MS-DRG assignment, and the assigned MS-DRG carries its specific relative weight.
CCDS Reference Topics: IPPS; MS-DRG relative weight; resource consumption; reimbursement methodology.
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NEW QUESTION # 82
An 82-year-old patient with a urinary infection develops an acute fluctuating disturbance in attention, disorganized thinking, and altered level of consciousness. The family states the patient was cognitively normal three days earlier. Which condition is MOST consistent with this presentation?
Answer: D
Explanation:
The presentation is most consistent with delirium, an acute and fluctuating disturbance in attention, awareness, and cognition that frequently develops in medically ill hospitalized patients.
The abrupt onset over several days and fluctuating cognitive state distinguish delirium from most forms of dementia, which generally develop progressively over months or years. Infection, medications, metabolic abnormalities, dehydration, hypoxia, and organ dysfunction are common precipitants.
A urinary infection may be a contributing clinical factor, but CDI should not automatically establish a cause- and-effect relationship between infection and delirium unless supported by provider documentation.
The CDI specialist should also recognize that terms such as "altered mental status" are symptoms rather than equivalent substitutes for a more specific diagnosis. When the clinical record contains sufficient indicators and the provider has documented only nonspecific mental-status terminology, a query may be warranted.
Intellectual disability represents a developmental condition rather than an acute change in cognition. A persistent vegetative state represents profound and persistent impairment of consciousness and is inconsistent with the described fluctuating presentation.
CCDS Reference Topics: Delirium; altered mental status; cognitive disorders; clinical indicators; documentation specificity.
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NEW QUESTION # 83
Hospital A is developing a query policy. Open-ended queries will be encouraged. The provider is expected to document on the query form, which will be retained as part of the health record. Hospital A will remove any unanswered queries and shred them to avoid any incomplete forms within the health record. Which of the following is considered a high-risk query practice?
Answer: D
Explanation:
The high-risk practice is destroying unanswered queries. Query retention should be governed by an established organizational policy and should not depend on whether the provider answers the query.
Selectively destroying unanswered queries can create significant compliance, audit, and record-integrity concerns because it removes evidence of the documentation-clarification process.
ACDIS/AHIMA guidance has consistently required organizations to establish query-retention policies.
Queries may be retained as part of the permanent health record or maintained as a retrievable business record according to organizational policy and legal requirements. The current 2026 ACDIS/AHIMA query practice guidance supersedes all previous editions, reinforcing the importance of a standardized, defensible query process.
Keeping queries in the health record is not inherently problematic when policy defines them as part of that record. Likewise, a new diagnosis may be included in a multiple-choice query when it is supported by patient- specific clinical indicators and the choices remain nonleading. A yes/no query can also be compliant in defined circumstances, such as clarification of a diagnosis or relationship already documented.
Selective destruction is therefore the clear compliance risk.
CCDS Reference Topics: Query retention; compliance; organizational query policy; audit integrity.
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NEW QUESTION # 84
Which of the following diagnoses is classified as a major complication/comorbidity (MCC) under the FY
2026 MS-DRG system?
Answer: C
Explanation:
Severe protein-calorie malnutrition is the correct answer. This question is adapted from an official CCDS sample question published by ACDIS.
Under the FY 2026 MS-DRG Definitions Manual, E43, unspecified severe protein-calorie malnutrition, is classified as an MCC. In contrast, moderate and mild protein-calorie malnutrition codes are classified as CCs rather than MCCs.
An MCC can materially affect MS-DRG assignment when the applicable DRG family differentiates cases by MCC status and when no exclusion or other grouper rule prevents the effect. However, the financial effect is never sufficient justification for a query. Documentation must be clinically supported and reflect the patient's actual condition.
A dietitian may document detailed nutrition findings and malnutrition criteria, but the reportable diagnosis ordinarily requires documentation by the provider responsible for establishing diagnoses. Therefore, when strong nutritional indicators exist but the provider has not documented malnutrition, a compliant query may be appropriate.
For CCDS preparation, candidates should understand both the clinical characteristics of malnutrition and its coding/reimbursement classification.
CCDS Reference Topics: MCCs; malnutrition; MS-DRG methodology; documentation requirements; IPPS.
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NEW QUESTION # 85
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