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| Section | Weight | Objectives |
|---|---|---|
| Anatomy and physiology, pathophysiology, pharmacology, and medical terminology | 19.17% | - Diseases and disorders of the nervous system - Alcohol/drug use and alcohol/drug-induced organic brain disorders - Diseases and disorders of the hepatobiliary system - Medications as clinical indicators - Endocrine, nutritional, and metabolic diseases and disorders - Myeloproliferative diseases and disorders and poorly differentiated neoplasms - Clinical indicators and query opportunities by Major Diagnostic Category - Infectious and parasitic diseases - Injuries, poisonings, and toxic effects of drugs - Diseases and disorders of the kidney and urinary tract - Mental diseases and disorders - Diseases and disorders of the circulatory system - Standard medical abbreviations - Pharmaceuticals and disease processes - Diseases and disorders of the digestive system - Diseases and disorders of the skin, subcutaneous tissue, and breast - Diagnostic tests as clinical indicators - Diseases and disorders of the blood and blood-forming organs and immunological disorders - HIV infections - Diseases and disorders of the musculoskeletal system - Diseases and disorders of the respiratory system |
| Impact of reportable diagnoses on quality of care | 8.33% | - Hospital-Acquired Condition Reduction Program - Healthcare-associated infections and complication codes - CDI impact on Hospital Value-Based Purchasing - Mortality reviews and observed/expected ratios - Coded data elements affecting Patient Safety Indicators - Quality data from record abstraction and claims data - Hospital Value-Based Purchasing - Patient Safety Indicators - Hospital Inpatient Quality Reporting Program - Documentation and code assignment impact on mortality index - 30-day mortality measures - Hospital Readmissions Reduction Program |
| Professionalism, ethics, and compliance | 9.17% | - CDI department goals beyond reimbursement - Medical record confidentiality - Leading queries - Compliance risks indicated by PEPPER - Potential DRG creep - DRG compliance initiatives |
| Healthcare regulations, reimbursement, and documentation requirements related to the IPPS | 12.5% | - Principal diagnosis and medical necessity - Coding and billing practices vulnerable to denial - Case mix index (CMI) - Medicare Severity Diagnosis Related Groups (MS-DRGs) - IPPS and its updates and revisions - Medical staff and clinical staff documentation responsibilities - Major complication/comorbidity (MCC) - Inpatient admission criteria and CMS Two-Midnight Rule - Complication/comorbidity (CC) - Documentation and medical necessity of setting - Medicare contractors and their impact on CDI - Documentation impact on IPPS reimbursement |
| Communication skills | 9.17% | - Reconciling CDI working DRGs with final coded DRGs - Roles and responsibilities of CDI specialists - Effective and non-confrontational physician communication - Physician education forms and tools - Educational presentations for healthcare departments and administration - Verbal versus written physician communication - Roles and responsibilities of coders working with CDI departments |
| Medical record documentation | 19.17% | - Types of physician queries - Translating clinical indicators into compliant queries - Compliant and noncompliant queries - Addressing diagnoses without clinical support - Provider role and diagnosis code assignment - Situations in which queries are not appropriate - Physician query formats - Documentation requiring clarification - ACDIS/AHIMA Guidelines for Achieving a Compliant Query Practice - When a physician query is warranted - Health record elements used for diagnosis and procedure code assignment - Clinical indicators |
| Official Guidelines for Coding and Reporting | 14.17% | - Secondary diagnosis assignment - AHA Coding Clinic - Principal diagnosis assignment - Working DRG assignment for multiple diagnoses - Present on admission indicators - Hospital-acquired conditions - Discharge dispositions and transfers - Coding guidelines for principal diagnosis selection - Official Guidelines for Coding and Reporting updates |
| Healthcare facility CDI program analysis | 8.33% | - Hospital-specific financial data - Hospital Value-Based Purchasing measures - CC/MCC capture - High-frequency DRGs - Publicly reported data - Case mix index (CMI) - Severity of illness and risk of mortality - CDI program forecasting - PEPPER data - CDI specialist productivity metrics - Patient Safety Indicators - Tracking and trending physician, department, and hospital performance - Physician performance measurement - Basic computer and software application skills - Provider response rates |
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NEW QUESTION # 13
The amount of the IPPS Indirect Medical Education Adjustment is determined by teaching intensity as measured by the hospital's number of residents compared to:
Answer: A
Explanation:
Medicare's Indirect Medical Education (IME) adjustment uses the hospital's resident-to-bed ratio as the principal measure of teaching intensity. CMS explains that the IME adjustment factor is calculated using a hospital's ratio of residents to beds. Therefore, the correct answer is inpatient beds.
IME is an additional IPPS payment intended to recognize the higher indirect patient-care costs associated with operating an approved teaching program. These costs are distinguished from Direct Graduate Medical Education payments, which reimburse qualifying direct costs associated with residency training.
The number of admissions is not the denominator in the IME teaching-intensity calculation. Likewise, emergency-department beds are not simply combined with inpatient beds for the standard resident-to-bed ratio, and disproportionate-share payment rates represent a separate IPPS adjustment related principally to hospitals caring for substantial numbers of low-income patients.
For the CCDS examination, the important distinction is that IPPS reimbursement involves more than the base MS-DRG payment. Adjustments may include IME, disproportionate-share hospital provisions, wage-index effects, outlier payments, and other statutory mechanisms.
CCDS Reference Topics: IPPS reimbursement; teaching hospitals; IME adjustment; resident-to-bed ratio.
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NEW QUESTION # 14
Documentation indicates an excisional debridement was performed without further specification. The CDI specialist should query to clarify which of the following?
Answer: C
Explanation:
The most critical missing element is the depth or level of tissue actually debrided. Documentation of an excisional debridement should identify whether tissue removed included skin, subcutaneous tissue, fascia, muscle, bone, or another anatomical layer. The level removed is fundamental to accurate procedural classification and coding.
CMS wound-care documentation standards similarly emphasize that the medical record should describe the type and depth of tissue removed. Merely knowing that an excisional debridement occurred does not establish the anatomical level of the procedure.
The instrument may provide useful procedural context-for example, scalpel, scissors, curette, or other technique-but the instrument alone does not identify the deepest tissue excised. Wound size can be important for clinical care and certain coding systems, but it does not replace documentation of the tissue level removed. The identity of the person performing the procedure is also part of procedural documentation but does not answer the principal coding-specific deficiency in this scenario.
A CDI query should therefore seek the deepest tissue level actually excised rather than infer it from the wound's overall depth.
CCDS Reference Topics: Medical record documentation; ICD-10-PCS/procedure documentation; debridement specificity.
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NEW QUESTION # 15
A patient is admitted with a documented diagnosis of acute hypoxic respiratory failure. Which of the following clinical data BEST supports the diagnosis?
Answer: A
Explanation:
Option A provides the strongest clinical support for acute hypoxic respiratory failure because it demonstrates substantial respiratory distress and progressive need for oxygen/ventilatory support. Tripod positioning is an objective sign of increased work of breathing. Escalation to a non-rebreather mask indicates a substantial oxygen requirement, and subsequent endotracheal intubation demonstrates failure of less invasive respiratory support.
Acute respiratory failure is ultimately a provider diagnosis, and no single oxygen-saturation threshold establishes it in every patient. A CDI specialist therefore evaluates the entire clinical picture: oxygenation, baseline respiratory status, work of breathing, arterial blood gases when available, escalating oxygen requirements, ventilatory support, and treatment intensity.
An SaO# of 91% on low-flow oxygen may represent clinically important hypoxemia, but without additional evidence it is less compelling than the severe respiratory compromise described in option A. Likewise, a patient with COPD who chronically uses 2 L/min oxygen and maintains an SaO# of 94% may simply be at baseline.
FY 2026 ICD-10-CM guidance recognizes acute respiratory failure as a reportable diagnosis and permits it as principal or secondary depending on the circumstances of admission.
CCDS Reference Topics: Respiratory failure; clinical indicators; pathophysiology; clinical validation.
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NEW QUESTION # 16
A patient with type 2 diabetes mellitus is admitted with stage 4 chronic kidney disease. The physician documents both conditions but does not explicitly state that the CKD is caused by diabetes. No documentation indicates that the conditions are unrelated. Which of the following is the MOST appropriate coding approach?
Answer: A
Explanation:
ICD-10-CM permits a presumed causal relationship between diabetes mellitus and certain conditions indexed under "diabetes, with," including chronic kidney disease. Therefore, when diabetes and CKD are both documented and the provider has not specifically indicated that they are unrelated, the diabetes-with-CKD combination code is assigned together with an additional code identifying the CKD stage.
For type 2 diabetes, diabetic CKD is classified to E11.22, while an N18.- code identifies the documented CKD stage. In this scenario, stage 4 CKD would be additionally represented by the appropriate stage-specific N18 code.
A query is not routinely necessary simply to obtain wording such as "diabetic CKD" when the classification itself establishes the presumed relationship. However, clarification would be appropriate if documentation explicitly states another unrelated etiology or contains contradictory information.
This distinction is important for CDI because excessive querying can create unnecessary provider burden.
CDI specialists must understand which diagnostic relationships require explicit provider linkage and which are established through ICD-10-CM conventions.
The FY 2026 Official Guidelines remain applicable to discharges through September 30, 2026.
CCDS Reference Topics: Diabetes; CKD; presumed causal relationships; combination codes; coding conventions.
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NEW QUESTION # 17
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: C
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 # 18
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