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| Section | Weight | Objectives |
|---|---|---|
| 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 |
| Clinical Documentation Review & Query Practices | 20% | - Concurrent and retrospective chart review methodologies - Documentation gap identification and resolution - Query development, communication, and ethical standards |
| CDI Program Management & Professional Practice | 15% | - Ethics, HIPAA, and professional conduct - Provider education and training strategies - Program metrics, benchmarks, and performance measurement |
| 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 |
| Healthcare Regulations, Reimbursement & Documentation Requirements – IPPS | 15% | - Inpatient Prospective Payment System (IPPS) fundamentals - Documentation responsibilities of medical and clinical staff - Medicare Severity Diagnostic Related Groups (MS-DRGs) |
| 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 |
努力する人生と努力しない人生は全然違いますなので、あなたはのんびりした生活だけを楽しみしていき、更なる進歩を求めるのではないか？スマートを一方に置いて、我々ACDISのCCDS試験問題集をピックアップします。弊社のCCDS試験問題集によって、あなたの心と精神の満足度を向上させながら、勉強した後CCDS試験資格認定書を受け取って努力する人生はすばらしいことであると認識られます。
質問 # 125
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?
正解：D
解説：
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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質問 # 126
A patient presents with crushing substernal chest pain, diaphoresis, ST-segment depression, and a significant rise and fall in cardiac troponin. The cardiologist documents acute coronary syndrome but does not specify the final diagnosis. Which clarification is MOST clinically appropriate?
正解：B
解説：
The clinical picture presents an appropriate opportunity to clarify whether the patient has NSTEMI, unstable angina, or another acute coronary diagnosis.
A significant rise and/or fall in cardiac troponin consistent with acute myocardial injury, together with ischemic symptoms and ECG abnormalities, strongly raises concern for acute myocardial infarction. In contrast, unstable angina generally refers to ischemia without the biomarker evidence required for myocardial infarction.
Nevertheless, CDI should not make the diagnosis independently. Troponin elevations can occur in multiple conditions, including myocarditis, pulmonary embolism, sepsis, tachyarrhythmia, renal disease, and other forms of myocardial injury.
Therefore, the cardiologist should be asked to clarify the final diagnosis based on the complete clinical evaluation.
GERD, chronic stable angina, and old MI do not adequately reflect the acute findings described.
For CCDS preparation, cardiovascular questions frequently require distinguishing symptoms from established diagnoses and understanding the clinical indicators associated with NSTEMI, STEMI, type 2 MI, and other myocardial injury categories.
The ACDIS candidate handbook identifies anatomy, physiology, pharmacology, pathophysiology, and clinical record analysis as essential examination competencies.
CCDS Reference Topics: NSTEMI; acute coronary syndrome; troponin; myocardial ischemia; diagnostic clarification.
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質問 # 127
A patient has chronic gastroesophageal reflux disease listed in the past medical history. During the current hospitalization for bacterial pneumonia, GERD receives no clinical evaluation, treatment, diagnostic testing, increased nursing monitoring, or effect on length of stay. Which statement is MOST accurate?
正解：A
解説：
A condition documented in the medical record does not automatically qualify as a reportable secondary diagnosis. For inpatient coding, additional diagnoses generally must be clinically significant during the current hospitalization. Qualifying significance includes clinical evaluation, therapeutic treatment, diagnostic procedures, an extended length of stay, or increased nursing care and/or monitoring.
Here, GERD is merely part of the patient's historical medical background and does not affect current management. Therefore, it generally should not be reported as an additional diagnosis solely because it appears in the past medical history.
Whether a diagnosis is classified as a CC or MCC is a separate issue. A condition must first satisfy applicable reporting requirements before its MS-DRG severity classification matters. CDI specialists should never encourage coding of clinically irrelevant historical conditions merely because they could affect reimbursement.
This principle protects the clinical integrity of coded data and prevents inappropriate inflation of disease burden. CDI review should focus on conditions that meaningfully describe the patient's current hospitalization, treatment requirements, clinical risk, and resource consumption.
CCDS Reference Topics: Reporting additional diagnoses; secondary-diagnosis criteria; medical-record review; resource utilization; coding compliance.
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質問 # 128
A patient has a history of a type 2 MI 30 days ago. The patient is admitted for chest pain which is determined to be an NSTEMI. Which of the following diagnosis(es) should be coded to identify the working MS-DRG?
正解：D
解説：
The current NSTEMI is the acute condition driving the admission. The prior type 2 myocardial infarction occurred 30 days earlier, placing it beyond the ICD-10-CM four-week acute-MI reporting window. The Official Guidelines state that category I21 codes may continue to be reported while an MI is four weeks old or less; after that period, an aftercare code may be appropriate when continued MI-related care is being provided, or I25.2 may describe an old/healed MI when applicable.
There is an additional reason not to select a "subsequent MI" answer. Category I22 is restricted to qualifying subsequent type 1 or unspecified acute myocardial infarctions occurring within four weeks of the initial qualifying MI. Type 2 MI is classified to I21.A1 rather than I22.
Therefore, the previous type 2 MI does not support selection of a subsequent-MI option in this 30-day scenario. The active NSTEMI is the diagnosis relevant to the working MS-DRG. "Initial encounter" in answer B is exam terminology rather than an ICD-10-CM seventh-character designation for MI, but B is clearly the intended correct choice.
CCDS Reference Topics: Official Guidelines-acute myocardial infarction; working MS-DRG; circulatory disorders.
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質問 # 129
A patient who underwent abdominal surgery one week ago is readmitted specifically for treatment of a postoperative wound infection documented by the surgeon as a complication of the procedure. Which condition should generally be considered for principal diagnosis selection?
正解：A
解説：
When a patient is admitted specifically for treatment of a documented postoperative complication, the complication is generally sequenced as the principal diagnosis when it is established after study to be chiefly responsible for the admission.
In this scenario, the surgeon has explicitly documented the wound infection as a complication of the prior procedure, and treatment of that complication is the reason for the current hospitalization. The original surgical disease therefore does not automatically remain the principal diagnosis simply because it led to the earlier operation.
Fever and abdominal pain are clinical manifestations or symptoms and ordinarily are not sequenced ahead of the definitive postoperative infection once that condition has been established.
A critical CDI principle is that a temporal relationship alone is insufficient to classify a postoperative condition as a complication. The provider must establish the appropriate relationship when required by ICD-
10-CM. Here, that documentation is already present, so a query simply asking whether the infection is postoperative would be unnecessary.
The principal-diagnosis decision should still account for all applicable complication-code sequencing instructions and circumstances of admission. The FY 2026 Official Guidelines emphasize both principal- diagnosis rules and requirements surrounding complications of care.
CCDS Reference Topics: Principal diagnosis; postoperative complications; complications of care; sequencing.
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質問 # 130
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最も効率的で直感的な学習方法を学習者に提供し、学習者が効率的に学習できるように最善を尽くします。 CCDS試験リファレンスは、クライアントにインスタンスを提供し、クライアントが直感的に理解できるようにします。ナレッジポイントを具体的に示すためのCCDSテストガイドのインスタンスがあるという考慮事項に基づいています。実際のCCDS試験を刺激することにより、クライアントは実際のCCDS試験練習問題の習熟度を理解できます。したがって、クライアントは抽象的な概念を直感的に理解できます。
CCDS練習問題: https://www.certjuken.com/CCDS-exam.html