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| Section | Weight | Objectives |
|---|---|---|
| Topic 1: Communication skills | 9.17% | - Verbal versus written physician communication - Educational presentations for healthcare departments and administration - Physician education forms and tools - Roles and responsibilities of coders working with CDI departments - Reconciling CDI working DRGs with final coded DRGs - Effective and non-confrontational physician communication - Roles and responsibilities of CDI specialists |
| Topic 2: Impact of reportable diagnoses on quality of care | 8.33% | - Documentation and code assignment impact on mortality index - Mortality reviews and observed/expected ratios - Quality data from record abstraction and claims data - Hospital-Acquired Condition Reduction Program - Healthcare-associated infections and complication codes - Hospital Value-Based Purchasing - Hospital Inpatient Quality Reporting Program - 30-day mortality measures - Coded data elements affecting Patient Safety Indicators - Patient Safety Indicators - Hospital Readmissions Reduction Program - CDI impact on Hospital Value-Based Purchasing |
| Topic 3: Medical record documentation | 19.17% | - Documentation requiring clarification - Compliant and noncompliant queries - Situations in which queries are not appropriate - Physician query formats - ACDIS/AHIMA Guidelines for Achieving a Compliant Query Practice - Clinical indicators - When a physician query is warranted - Health record elements used for diagnosis and procedure code assignment - Provider role and diagnosis code assignment - Addressing diagnoses without clinical support - Types of physician queries - Translating clinical indicators into compliant queries |
| Topic 4: Anatomy and physiology, pathophysiology, pharmacology, and medical terminology | 19.17% | - Diseases and disorders of the circulatory system - Pharmaceuticals and disease processes - Injuries, poisonings, and toxic effects of drugs - Diagnostic tests as clinical indicators - Diseases and disorders of the hepatobiliary system - Diseases and disorders of the kidney and urinary tract - Clinical indicators and query opportunities by Major Diagnostic Category - Endocrine, nutritional, and metabolic diseases and disorders - Myeloproliferative diseases and disorders and poorly differentiated neoplasms - Diseases and disorders of the blood and blood-forming organs and immunological disorders - Alcohol/drug use and alcohol/drug-induced organic brain disorders - Mental diseases and disorders - Diseases and disorders of the nervous system - Diseases and disorders of the musculoskeletal system - Infectious and parasitic diseases - Diseases and disorders of the digestive system - Medications as clinical indicators - Diseases and disorders of the respiratory system - HIV infections - Diseases and disorders of the skin, subcutaneous tissue, and breast - Standard medical abbreviations |
| Topic 5: Healthcare facility CDI program analysis | 8.33% | - PEPPER data - Hospital-specific financial data - Tracking and trending physician, department, and hospital performance - Severity of illness and risk of mortality - Basic computer and software application skills - Patient Safety Indicators - Publicly reported data - High-frequency DRGs - Physician performance measurement - Hospital Value-Based Purchasing measures - CDI specialist productivity metrics - Case mix index (CMI) - CDI program forecasting - Provider response rates - CC/MCC capture |
| Topic 6: Official Guidelines for Coding and Reporting | 14.17% | - Working DRG assignment for multiple diagnoses - Principal diagnosis assignment - Secondary diagnosis assignment - AHA Coding Clinic - Hospital-acquired conditions - Present on admission indicators - Coding guidelines for principal diagnosis selection - Discharge dispositions and transfers - Official Guidelines for Coding and Reporting updates |
| Topic 7: Professionalism, ethics, and compliance | 9.17% | - Medical record confidentiality - Compliance risks indicated by PEPPER - Potential DRG creep - CDI department goals beyond reimbursement - DRG compliance initiatives - Leading queries |
| Topic 8: Healthcare regulations, reimbursement, and documentation requirements related to the IPPS | 12.5% | - Medicare Severity Diagnosis Related Groups (MS-DRGs) - Coding and billing practices vulnerable to denial - Complication/comorbidity (CC) - IPPS and its updates and revisions - Documentation and medical necessity of setting - Medicare contractors and their impact on CDI - Documentation impact on IPPS reimbursement - Case mix index (CMI) - Medical staff and clinical staff documentation responsibilities - Inpatient admission criteria and CMS Two-Midnight Rule - Principal diagnosis and medical necessity - Major complication/comorbidity (MCC) |
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NEW QUESTION # 143
Under the FY 2026 Hospital Value-Based Purchasing Program, hospital performance is organized into which of the following four domains?
Answer: D
Explanation:
For FY 2026, CMS Hospital Value-Based Purchasing performance is organized into four domains: Clinical Outcomes; Person and Community Engagement; Safety; and Efficiency and Cost Reduction. CMS reports that each domain contributes to the hospital's Total Performance Score, with the FY 2026 dataset showing weighted scores for all four domains.
The Hospital VBP Program is funded by reducing participating hospitals' base operating DRG payments by
2% and redistributing the amount through value-based incentive payments according to program performance.
CDI professionals are particularly relevant to quality reporting because complete and accurate documentation can influence coded clinical information used in mortality, complications, risk adjustment, patient-safety analysis, and other quality processes. Documentation integrity should not be manipulated to improve scores; rather, the health record must accurately reflect the patient's actual severity and clinical course.
ACDIS explicitly includes Hospital VBP measures, SOI/ROM, Patient Safety Indicators, and publicly reported quality data within CCDS program-analysis competencies.
CCDS Reference Topics: Hospital VBP; quality reporting; Safety domain; Clinical Outcomes; CDI impact on publicly reported data.
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NEW QUESTION # 144
A physician documents "postoperative urinary retention" after surgery. The patient required temporary catheterization, but the surgeon indicates that urinary retention is a common expected consequence of anesthesia in this case. What should the CDI specialist do before treating the condition as a postoperative complication?
Answer: C
Explanation:
The CDI specialist should clarify whether the urinary retention represents an actual postoperative complication or an expected consequence of surgery/anesthesia.
ICD-10-CM does not classify every condition that occurs after medical or surgical care as a complication.
Provider documentation must establish the appropriate relationship when required, and the condition should represent more than an expected physiologic consequence.
Temporary urinary retention can occur after anesthesia, opioid administration, pelvic surgery, or immobilization. Its appearance following surgery therefore does not automatically establish a complication of care.
The query should objectively present the postoperative urinary retention, catheterization, duration, treatment, and any surgeon or anesthesia documentation indicating whether the event was expected. The provider can then characterize the condition appropriately.
Automatically assigning a device-related complication would introduce another unsupported causal relationship. CDI also cannot delete the documented condition simply because it may be expected.
This distinction is important because complication codes can influence MS-DRG assignment, quality reporting, patient-safety analyses, and public performance information. Accurate characterization is therefore essential.
CCDS Reference Topics: Complications of care; postoperative urinary retention; cause-and-effect relationship; clinical clarification.
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NEW QUESTION # 145
A CDI specialist submits a neutral query regarding possible acute blood loss anemia. The physician answers
"clinically unable to determine." The CDI specialist believes documenting the diagnosis would increase reimbursement substantially. What is the MOST appropriate next action?
Answer: A
Explanation:
The provider's response should be respected unless new information or a genuine unresolved documentation issue creates a legitimate reason for additional clarification.
"Clinically unable to determine" is an acceptable professional conclusion when the available evidence does not permit the provider to confidently establish a diagnosis. A CDI specialist must not continue sending essentially the same query simply because a different response would produce more favorable reimbursement.
Likewise, CDI cannot alter the provider's response or instruct coding personnel to assign a diagnosis that the provider declined to establish.
The 2026 ACDIS/AHIMA Guidelines for Achieving a Compliant Query Practice supersede all previous versions and serve as the current foundational resource for query processes. The query process is intended to improve the accuracy, completeness, and integrity of documentation-not to secure a predetermined financial result.
A legitimate follow-up could occur if new laboratory values, operative findings, transfusion information, pathology, or other material information emerges after the original response and creates a materially different clarification question.
Professional CDI practice requires balancing clinical advocacy with provider autonomy, ethical conduct, and regulatory compliance.
CCDS Reference Topics: Provider query responses; ethical CDI practice; repeated queries; provider independence; compliance.
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NEW QUESTION # 146
A patient is admitted with a stage 4 pressure ulcer of the right heel. The physician documents the pressure- ulcer diagnosis and location. The wound-care nurse documents stage 4. Which statement is MOST accurate?
Answer: B
Explanation:
Pressure-ulcer staging is one of the recognized circumstances in which ICD-10-CM permits the relevant clinical detail to be obtained from documentation by an appropriate non-provider clinician, such as a qualified wound-care nurse.
The provider establishes the medical diagnosis, while the wound-care clinician's specialized assessment may support the stage assignment. This distinction allows coding to reflect the expertise of clinicians who directly assess the wound without requiring physicians to duplicate every technical staging statement.
Option C is too broad. The exception permitting stage documentation from another clinician does not grant non-provider documentation unrestricted authority to establish all reportable medical diagnoses.
Pressure-ulcer stage is highly relevant because ICD-10-CM pressure-ulcer codes incorporate both anatomical site and stage. It can also have substantial implications for severity reporting, POA assessment, CMS HAC policy, nursing care, quality review, and risk adjustment.
When different clinicians document conflicting stages, clarification should be pursued rather than selecting the most severe value.
CCDS candidates should understand the distinction between provider-established diagnoses and specific coding elements that ICD-10-CM permits to originate from other qualified professionals.
CCDS Reference Topics: Pressure ulcers; wound staging; non-provider documentation; coding exceptions.
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NEW QUESTION # 147
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 # 148
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