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| Section | Weight | Objectives |
|---|---|---|
| Topic 1: Clinical Knowledge & Disease Processes Application | 20% | - Clinical indicators, lab results, medications, diagnostic findings - Disease processes across body systems applied to chart review - Medical terminology, anatomy, physiology, pathophysiology |
| Topic 2: CDI Program Management & Professional Practice | 15% | - Ethics, HIPAA, and professional conduct - Provider education and training strategies - Program metrics, benchmarks, and performance measurement |
| Topic 3: Coding Guidelines & Official Reporting Standards | 15% | - ICD-10-CM/PCS Official Guidelines for Coding and Reporting - AHIMA/ACDIS Guidelines for Compliant Query Practice - Coding integrity and compliant documentation practices |
| Topic 4: Quality, Risk Adjustment & Health Initiatives | 15% | - Severity of Illness (SOI) / Risk of Mortality (ROM) - Risk adjustment models and documentation impact - Quality reporting, public reporting, and compliance programs |
| Topic 5: Healthcare Regulations, Reimbursement & Documentation Requirements – IPPS | 15% | - Documentation responsibilities of medical and clinical staff - Inpatient Prospective Payment System (IPPS) fundamentals - Medicare Severity Diagnostic Related Groups (MS-DRGs) |
| Topic 6: Clinical Documentation Review & Query Practices | 20% | - Documentation gap identification and resolution - Concurrent and retrospective chart review methodologies - Query development, communication, and ethical standards |
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NEW QUESTION # 121
Under the FY 2026 Hospital Value-Based Purchasing Program, hospital performance is organized into which of the following four domains?
Answer: C
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 # 122
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: D
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 # 123
The attending physician documents "severe protein-calorie malnutrition." The dietitian's assessment documents normal nutritional intake, stable body weight, no fat loss, and no muscle wasting. What should the CDI specialist do?
Answer: B
Explanation:
This is an appropriate clinical validation query because the provider has documented a diagnosis while the available clinical information appears inconsistent with that diagnosis.
The CDI specialist should not automatically accept every documented diagnosis when substantial contradictory clinical evidence exists. Conversely, CDI cannot independently delete the physician's diagnosis or replace the physician's clinical judgment.
The query should objectively identify the documented severe malnutrition and relevant contradictory findings-for example, stable weight, adequate nutritional intake, and absence of documented muscle or fat loss-and ask the provider to clarify whether severe malnutrition remains clinically appropriate, whether another nutritional condition better describes the patient, whether the diagnosis has been ruled out, or whether additional clinical reasoning supports it.
The query must remain neutral and should not mention the MCC status or potential reimbursement effect of severe malnutrition.
The August 2026 ACDIS/AHIMA compliant-query guidance supersedes previous editions and is the current foundational standard for compliant documentation clarification.
CCDS Reference Topics: Clinical validation; malnutrition; conflicting clinical indicators; compliant queries; documentation integrity.
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NEW QUESTION # 124
The progress note on hospital day 2 of a patient's admission states that the patient got up from the bed to go to the bathroom just after housekeeping had mopped the floor. The patient slipped and fell onto the floor, sustaining a broken wrist. The diagnosis of a fractured wrist will:
Answer: A
Explanation:
The fracture occurred after inpatient admission as the result of a hospital fall, placing it within CMS's Hospital-Acquired Condition category for Falls and Trauma when the applicable fracture code is included in the HAC code list. CMS's FY 2026 MS-DRG Definitions Manual continues to identify qualifying fracture codes within HAC 05.
The fracture must still be coded; therefore, option D is incorrect. Because it clearly developed after admission, it would not appropriately receive POA indicator "U," which indicates insufficient documentation to determine whether the condition was present on admission.
For qualifying HAC diagnoses that are not POA, CMS payment logic prevents the hospital from receiving the higher MS-DRG payment that would otherwise result solely from the condition's CC/MCC status. Thus, option B expresses the intended payment effect.
This distinction is central to CDI practice: a hospital-acquired diagnosis does not disappear from the record or coding. It remains reportable for clinical and quality purposes, but certain qualifying HACs are treated differently in MS-DRG payment calculations.
CCDS Reference Topics: HACs; POA indicators; Falls and Trauma; MS-DRG payment adjustment.
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NEW QUESTION # 125
A registered dietitian documents severe malnutrition based on substantial weight loss, severe muscle depletion, and prolonged inadequate energy intake. The attending physician documents only "poor oral intake." What is the BEST action for the CDI specialist?
Answer: C
Explanation:
The appropriate action is to query the provider regarding the patient's nutritional diagnosis. The dietitian's assessment supplies important clinical evidence, but the associated diagnosis of malnutrition generally must be documented by an appropriate provider before the diagnosis code is assigned.
The FY 2026 ICD-10-CM Official Guidelines permit selected elements to come from non-provider clinicians-such as BMI, pressure-ulcer stage, coma scale, NIH Stroke Scale, certain social determinants, and other specifically identified exceptions. Malnutrition diagnosis itself is not simply assigned solely from a dietitian's diagnostic statement under this general rule.
Ignoring the dietitian's findings would also be inappropriate. CDI review should integrate multidisciplinary documentation because such documentation can reveal valid clarification opportunities. Severe weight loss, reduced intake, and documented muscle depletion provide a clinical basis for a neutral query.
The query should not state that severe malnutrition "must" be documented because it is an MCC. Instead, it should present the relevant nutrition findings and allow the provider to determine the diagnosis, including severe malnutrition, another level of malnutrition, another cause, or inability to determine.
CCDS Reference Topics: Malnutrition; multidisciplinary documentation; provider diagnosis requirements; clinical indicators.
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NEW QUESTION # 126
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