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| Section | Weight | Objectives |
|---|---|---|
| Topic 1: Anatomy and physiology, pathophysiology, pharmacology, and medical terminology | 19.17% | - Diseases and disorders of the nervous system - Standard medical abbreviations - Infectious and parasitic diseases - Diseases and disorders of the kidney and urinary tract - Diseases and disorders of the hepatobiliary system - Mental diseases and disorders - Endocrine, nutritional, and metabolic diseases and disorders - Clinical indicators and query opportunities by Major Diagnostic Category - Diseases and disorders of the musculoskeletal system - Alcohol/drug use and alcohol/drug-induced organic brain disorders - Diseases and disorders of the digestive system - Myeloproliferative diseases and disorders and poorly differentiated neoplasms - Diseases and disorders of the skin, subcutaneous tissue, and breast - Injuries, poisonings, and toxic effects of drugs - Diseases and disorders of the blood and blood-forming organs and immunological disorders - Pharmaceuticals and disease processes - Medications as clinical indicators - Diseases and disorders of the circulatory system - Diseases and disorders of the respiratory system - HIV infections - Diagnostic tests as clinical indicators |
| Topic 2: Communication skills | 9.17% | - Physician education forms and tools - Roles and responsibilities of CDI specialists - Roles and responsibilities of coders working with CDI departments - Effective and non-confrontational physician communication - Educational presentations for healthcare departments and administration - Reconciling CDI working DRGs with final coded DRGs - Verbal versus written physician communication |
| Topic 3: Official Guidelines for Coding and Reporting | 14.17% | - Working DRG assignment for multiple diagnoses - Present on admission indicators - AHA Coding Clinic - Hospital-acquired conditions - Secondary diagnosis assignment - Principal diagnosis assignment - Discharge dispositions and transfers - Coding guidelines for principal diagnosis selection - Official Guidelines for Coding and Reporting updates |
| Topic 4: Healthcare facility CDI program analysis | 8.33% | - Hospital-specific financial data - CDI specialist productivity metrics - Provider response rates - Case mix index (CMI) - Severity of illness and risk of mortality - Patient Safety Indicators - Physician performance measurement - CDI program forecasting - Hospital Value-Based Purchasing measures - Publicly reported data - PEPPER data - CC/MCC capture - Basic computer and software application skills - High-frequency DRGs - Tracking and trending physician, department, and hospital performance |
| Topic 5: Impact of reportable diagnoses on quality of care | 8.33% | - Quality data from record abstraction and claims data - CDI impact on Hospital Value-Based Purchasing - Coded data elements affecting Patient Safety Indicators - Hospital-Acquired Condition Reduction Program - Hospital Readmissions Reduction Program - Healthcare-associated infections and complication codes - Hospital Inpatient Quality Reporting Program - Patient Safety Indicators - Hospital Value-Based Purchasing - 30-day mortality measures - Mortality reviews and observed/expected ratios - Documentation and code assignment impact on mortality index |
| Topic 6: Medical record documentation | 19.17% | - Types of physician queries - Documentation requiring clarification - Health record elements used for diagnosis and procedure code assignment - Situations in which queries are not appropriate - ACDIS/AHIMA Guidelines for Achieving a Compliant Query Practice - Translating clinical indicators into compliant queries - Physician query formats - Clinical indicators - Provider role and diagnosis code assignment - Compliant and noncompliant queries - Addressing diagnoses without clinical support - When a physician query is warranted |
| Topic 7: Healthcare regulations, reimbursement, and documentation requirements related to the IPPS | 12.5% | - Documentation and medical necessity of setting - Documentation impact on IPPS reimbursement - Case mix index (CMI) - Medicare Severity Diagnosis Related Groups (MS-DRGs) - Complication/comorbidity (CC) - Medical staff and clinical staff documentation responsibilities - IPPS and its updates and revisions - Principal diagnosis and medical necessity - Major complication/comorbidity (MCC) - Medicare contractors and their impact on CDI - Inpatient admission criteria and CMS Two-Midnight Rule - Coding and billing practices vulnerable to denial |
| Topic 8: Professionalism, ethics, and compliance | 9.17% | - Compliance risks indicated by PEPPER - Medical record confidentiality - Leading queries - CDI department goals beyond reimbursement - DRG compliance initiatives - Potential DRG creep |
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NEW QUESTION # 101
After a month of intermittent antibiotic use, the patient is admitted. An infectious-control physician documents a diagnosis of Clostridium difficile in the inpatient medical record. Which domain of the MOST current Hospital Value-Based Purchasing program would this diagnosis impact?
Answer: A
Explanation:
The relevant Hospital Value-Based Purchasing domain is the Safety domain, corresponding most closely to option D. CMS's FY 2026 Hospital VBP program maintains a Safety domain that includes healthcare- associated infection performance measures, including C. difficile infection. CMS's current VBP Safety dataset specifically identifies C. difficile among its healthcare-associated infection measures.
It is important to distinguish the domain from an individual measure. "Hospital-acquired infection" describes the type of quality measure, but the formal broader scoring domain is Safety. PSI 90 is also associated with patient safety measurement, but it is not the name of the overall VBP domain.
From a CDI standpoint, documentation accuracy matters because coded and quality-reporting data can influence organizational performance assessment. However, documentation of C. difficile alone does not automatically establish that an infection qualifies as a hospital-onset event for every quality program. Timing and the applicable measure specifications determine whether an individual episode enters a particular healthcare-associated infection metric.
Therefore, CDI professionals should accurately capture the infection and its clinical circumstances without attempting to classify an event as hospital acquired solely to influence quality scores.
CCDS Reference Topics: Hospital VBP; Safety domain; healthcare-associated infections; C. difficile; quality reporting.
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NEW QUESTION # 102
A neurologist documents acute cerebral infarction. A qualified stroke nurse records the NIH Stroke Scale score in the medical record. Which statement is MOST accurate?
Answer: A
Explanation:
ICD-10-CM permits the NIH Stroke Scale score to be reported from documentation by an appropriate clinician other than the provider responsible for establishing the diagnosis. The underlying stroke diagnosis itself must be appropriately documented by the provider.
This is similar to other specified exceptions such as BMI, pressure-ulcer stage, coma scale values, and certain additional clinical elements for which qualified non-provider documentation may support code assignment.
The exception does not mean that a stroke nurse can independently establish cerebral infarction for coding.
Rather, once the provider has documented the stroke, the nurse's formal NIHSS assessment can supply the standardized severity measurement.
This approach recognizes that specially trained clinical professionals routinely collect and document these structured measurements as part of patient care.
If multiple NIHSS values are documented, the applicable coding instructions and timing requirements should be followed rather than simply selecting the highest score because it produces a different code.
For CDI professionals, awareness of these non-provider documentation exceptions prevents unnecessary physician queries while ensuring that important severity information is not lost.
CCDS Reference Topics: NIH Stroke Scale; cerebral infarction; non-provider documentation; coding exceptions; stroke severity.
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NEW QUESTION # 103
The PRIMARY goal of a CDI specialist's work is to support complete and specific documentation that results in:
Answer: D
Explanation:
The fundamental objective of clinical documentation integrity is to ensure that the health record accurately represents the patient's clinical condition, including severity of illness, complexity, acuity, diagnoses, treatments, and outcomes. Reimbursement is an important downstream consequence of documentation and coding, but maximizing reimbursement is not the primary professional objective of CDI.
The ACDIS CCDS framework describes the CDI specialist as applying clinical knowledge to determine how documentation translates into coded data and educating providers so the record appropriately reflects severity, complexity, and acuity. This distinction is critical from an ethics and compliance perspective. A CDI program must pursue documentation accuracy whether clarification raises, lowers, or leaves reimbursement unchanged.
Reducing HACs is principally a clinical-quality and patient-safety function. CDI can improve the accuracy with which HACs are identified and reported, but it does not directly prevent those conditions. Similarly, improved provider communication is an important mechanism used by CDI professionals, but it is a means toward accurate documentation rather than the primary endpoint.
Therefore, A most accurately captures the broad clinical, coding, quality, and compliance purpose of CDI.
CCDS Reference Topics: Professionalism, ethics, and compliance; Medical record documentation; goals of CDI beyond reimbursement.
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NEW QUESTION # 104
A patient undergoes abdominal surgery. Two days later, the physician documents "postoperative anemia." The hemoglobin decreased from 12.4 g/dL preoperatively to 8.2 g/dL, but the record does not state whether the anemia represents an expected postoperative condition, acute blood loss anemia, or a complication of surgery. What should the CDI specialist do?
Answer: C
Explanation:
The appropriate action is to query for clarification. A temporal relationship-anemia occurring after surgery- does not automatically establish that a reportable complication occurred. Likewise, a CDI specialist cannot independently translate a substantial hemoglobin decline into acute posthemorrhagic anemia without provider documentation.
The FY 2026 Official Guidelines state that complication-of-care code assignment depends on provider documentation establishing the relationship between the condition and the care or procedure unless the classification specifically instructs otherwise. They also emphasize that not every condition occurring during or following medical care is a complication.
The query could present the preoperative and postoperative hemoglobin values, estimated blood loss, transfusions, clinical monitoring, and treatment. Appropriate response options might include acute blood loss anemia, expected postoperative anemia, another diagnosis, or clinically unable to determine, depending on the record.
Option A overstates causation. Option B independently diagnoses the patient from laboratory findings. Option D is equally inappropriate because clinically significant postoperative anemia may be reportable.
CCDS Reference Topics: Complications of care; postoperative anemia; clinical indicators; cause-and-effect clarification; compliant querying.
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NEW QUESTION # 105
A patient accidentally takes twice the prescribed dose of warfarin and develops gastrointestinal bleeding.
Which coding concept applies?
Answer: A
Explanation:
Taking more medication than prescribed constitutes poisoning under ICD-10-CM drug-event rules. The drug may have been correctly prescribed, but the patient took an incorrect amount.
For poisoning, the applicable poisoning code is generally sequenced first, followed by codes identifying manifestations such as gastrointestinal bleeding.
This differs from an adverse effect, in which a drug is correctly prescribed and properly administered but causes an undesirable reaction. In adverse-effect scenarios, the nature of the adverse effect is coded first, followed by the drug code with the appropriate adverse-effect character.
Underdosing applies when the patient takes less of a medication than prescribed, whether intentionally or unintentionally. It does not describe excessive dosing.
For CDI specialists, determining whether an event represents poisoning, adverse effect, or underdosing requires careful review of how the medication was prescribed and actually taken. Phrases such as "warfarin- related bleeding" may not always provide enough information to determine the correct classification.
A clarification query may therefore be appropriate when dose, intent, or medication-use circumstances are unclear.
CCDS Reference Topics: Poisoning; adverse effects; underdosing; medication events; sequencing.
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NEW QUESTION # 106
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