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| Section | Weight | Objectives |
|---|---|---|
| Topic 1: Official Guidelines for Coding and Reporting | 14.17% | - Hospital-acquired conditions - Working DRG assignment for multiple diagnoses - AHA Coding Clinic - Coding guidelines for principal diagnosis selection - Discharge dispositions and transfers - Present on admission indicators - Secondary diagnosis assignment - Principal diagnosis assignment - Official Guidelines for Coding and Reporting updates |
| Topic 2: Professionalism, ethics, and compliance | 9.17% | - Leading queries - Medical record confidentiality - Compliance risks indicated by PEPPER - DRG compliance initiatives - Potential DRG creep - CDI department goals beyond reimbursement |
| Topic 3: Communication skills | 9.17% | - Roles and responsibilities of coders working with CDI departments - Reconciling CDI working DRGs with final coded DRGs - Educational presentations for healthcare departments and administration - Verbal versus written physician communication - Roles and responsibilities of CDI specialists - Physician education forms and tools - Effective and non-confrontational physician communication |
| Topic 4: Anatomy and physiology, pathophysiology, pharmacology, and medical terminology | 19.17% | - Infectious and parasitic diseases - Diseases and disorders of the hepatobiliary system - Pharmaceuticals and disease processes - Diseases and disorders of the blood and blood-forming organs and immunological disorders - Clinical indicators and query opportunities by Major Diagnostic Category - Diseases and disorders of the respiratory system - Diseases and disorders of the nervous system - Standard medical abbreviations - Diseases and disorders of the digestive system - Diseases and disorders of the musculoskeletal system - Diseases and disorders of the skin, subcutaneous tissue, and breast - Alcohol/drug use and alcohol/drug-induced organic brain disorders - Diagnostic tests as clinical indicators - Injuries, poisonings, and toxic effects of drugs - Diseases and disorders of the kidney and urinary tract - Mental diseases and disorders - Medications as clinical indicators - Endocrine, nutritional, and metabolic diseases and disorders - Myeloproliferative diseases and disorders and poorly differentiated neoplasms - Diseases and disorders of the circulatory system - HIV infections |
| Topic 5: Impact of reportable diagnoses on quality of care | 8.33% | - Documentation and code assignment impact on mortality index - Hospital Inpatient Quality Reporting Program - Hospital Value-Based Purchasing - Patient Safety Indicators - CDI impact on Hospital Value-Based Purchasing - Hospital Readmissions Reduction Program - Hospital-Acquired Condition Reduction Program - Mortality reviews and observed/expected ratios - Healthcare-associated infections and complication codes - 30-day mortality measures - Quality data from record abstraction and claims data - Coded data elements affecting Patient Safety Indicators |
| Topic 6: Healthcare regulations, reimbursement, and documentation requirements related to the IPPS | 12.5% | - Medical staff and clinical staff documentation responsibilities - Documentation impact on IPPS reimbursement - Complication/comorbidity (CC) - IPPS and its updates and revisions - Documentation and medical necessity of setting - Major complication/comorbidity (MCC) - Medicare Severity Diagnosis Related Groups (MS-DRGs) - Medicare contractors and their impact on CDI - Principal diagnosis and medical necessity - Coding and billing practices vulnerable to denial - Inpatient admission criteria and CMS Two-Midnight Rule - Case mix index (CMI) |
| Topic 7: Healthcare facility CDI program analysis | 8.33% | - Severity of illness and risk of mortality - Hospital Value-Based Purchasing measures - Publicly reported data - Basic computer and software application skills - CDI program forecasting - Patient Safety Indicators - CC/MCC capture - PEPPER data - Hospital-specific financial data - High-frequency DRGs - Tracking and trending physician, department, and hospital performance - Physician performance measurement - Provider response rates - Case mix index (CMI) - CDI specialist productivity metrics |
| Topic 8: Medical record documentation | 19.17% | - Translating clinical indicators into compliant queries - Compliant and noncompliant queries - Clinical indicators - When a physician query is warranted - Types of physician queries - ACDIS/AHIMA Guidelines for Achieving a Compliant Query Practice - Provider role and diagnosis code assignment - Documentation requiring clarification - Health record elements used for diagnosis and procedure code assignment - Physician query formats - Situations in which queries are not appropriate - Addressing diagnoses without clinical support |
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76. Frage
Which of the following is considered by CMS to be a HAC requiring MS-DRG adjustment if not POA?
Antwort: B
Begründung:
CMS specifically includes deep vein thrombosis and pulmonary embolism following certain orthopedic procedures, including total knee replacement and hip replacement, among Hospital-Acquired Conditions subject to the HAC/POA payment provisions. Therefore, option C is correct.
Under the IPPS HAC payment policy, qualifying conditions that were not present on admission may lose their normal CC/MCC effect for MS-DRG assignment when all applicable criteria are met. This makes accurate POA determination essential in CDI and coding.
Pressure ulcers are also part of the HAC framework, but the CMS category historically applies specifically to Stage III and Stage IV pressure ulcers. An unstageable pressure ulcer does not automatically satisfy the Stage III/IV HAC category merely because it is severe or clinically significant. CMS materials distinguish an unstageable ulcer from a documented Stage III or IV ulcer.
Postoperative pneumonia and septic shock are not, by themselves, the specified HAC category represented by the answer choices.
The CCDS blueprint specifically requires candidates to identify CMS-designated HACs and understand the effect of POA assignment on payment.
CCDS Reference Topics: IPPS; Hospital-Acquired Conditions; POA; MS-DRG adjustment.
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77. Frage
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?
Antwort: B
Begründung:
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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78. Frage
An operative report states that the surgeon performed an excisional debridement of a heel wound. The report documents removal of necrotic tissue but does not identify the deepest tissue level removed. What should the CDI specialist clarify?
Antwort: D
Begründung:
For excisional debridement, documentation of the deepest tissue level actually removed is essential for accurate ICD-10-PCS procedure assignment. Relevant levels may include skin, subcutaneous tissue, fascia, muscle, or bone.
The presence of a deep wound does not establish that debridement reached the deepest anatomical layer visible in the wound. For example, a wound may extend to muscle while the physician removes only necrotic subcutaneous tissue. Coding must reflect the body part and tissue actually debrided rather than the overall depth of the wound.
Therefore, the CDI specialist should clarify what tissue was excised. Other procedural elements may already be supported by the operative documentation, including the excisional nature of the procedure.
The number of instruments or duration of anesthesia does not determine the applicable body-part value.
Similarly, administrative details have no bearing on procedural specificity.
CDI specialists working with surgical records must understand the distinction between wound description and procedure performance. Accurate procedural documentation can affect ICD-10-PCS coding and ultimately MS-DRG assignment, particularly when an operating-room procedure influences grouper logic.
The CCDS competency framework includes medical-record review and coding/payment implications of inpatient procedures.
CCDS Reference Topics: Excisional debridement; ICD-10-PCS; tissue depth; operative documentation.
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79. Frage
A CDI specialist has been asked to present a report to hospital administration that will demonstrate the CDI program's impact over time. Which of the following reports will BEST accomplish this?
Antwort: B
Begründung:
A line graph showing Risk of Mortality (ROM) and Severity of Illness (SOI) by month provides the strongest evidence of program impact over time because it displays longitudinal trends. Hospital leadership can readily determine whether documented patient complexity and risk profiles are increasing, decreasing, or remaining stable and can correlate those trends with CDI interventions.
The CCDS content outline specifically requires CDI specialists to analyze program trends, use SOI/ROM and other program-performance methodologies, create forecasting data, evaluate hospital performance, and track metrics over time. A line graph is particularly appropriate because time is the independent variable and changes from month to month are immediately visible.
An individual specialist's query rate primarily measures productivity or workflow rather than overall organizational impact. A pie graph of unanswered queries provides a snapshot of one process metric, not longitudinal program effectiveness. A presentation of program goals and objectives communicates strategy but does not demonstrate measurable results.
ROM and SOI also connect CDI work to quality and risk-adjustment outcomes, making them particularly meaningful to senior hospital administration.
CCDS Reference Topics: Healthcare facility CDI program analysis; trend analysis; SOI/ROM; physician and hospital performance.
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80. Frage
A patient is admitted with sepsis due to osteomyelitis and evidence of organ failure. Which of the following is the correct principal diagnosis?
Antwort: B
Begründung:
The underlying systemic infection/sepsis code is sequenced as the principal diagnosis when sepsis or severe sepsis is present on admission and is the condition chiefly responsible for admission. Therefore, sepsis is the correct selection from the available choices.
The presence of organ failure means the patient may also meet the documentation requirements for severe sepsis when the acute organ dysfunction is explicitly associated with the sepsis. However, the severe-sepsis code from subcategory R65.2- cannot be assigned as the principal diagnosis. The FY 2026 ICD-10-CM Official Guidelines require the underlying systemic infection first, followed by R65.2- and codes for the associated acute organ dysfunction.
Osteomyelitis represents the localized infection source, but when the reason for admission is sepsis associated with that localized infection, the systemic infection is sequenced first under the sepsis guidelines.
"Septicemia" should not be substituted for provider-documented sepsis.
The CDI specialist should also verify that the provider has clearly linked the organ failure to sepsis before severe-sepsis coding is applied.
CCDS Reference Topics: Sepsis sequencing; severe sepsis; principal diagnosis; localized infection.
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81. Frage
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