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| Section | Weight | Objectives |
|---|---|---|
| Topic 1: Coding Guidelines & Official Reporting Standards | 15% | - ICD-10-CM/PCS Official Guidelines for Coding and Reporting - Coding integrity and compliant documentation practices - AHIMA/ACDIS Guidelines for Compliant Query Practice |
| Topic 2: Quality, Risk Adjustment & Health Initiatives | 15% | - Quality reporting, public reporting, and compliance programs - Risk adjustment models and documentation impact - Severity of Illness (SOI) / Risk of Mortality (ROM) |
| Topic 3: Clinical Documentation Review & Query Practices | 20% | - Concurrent and retrospective chart review methodologies - Documentation gap identification and resolution - Query development, communication, and ethical standards |
| Topic 4: Healthcare Regulations, Reimbursement & Documentation Requirements – IPPS | 15% | - Medicare Severity Diagnostic Related Groups (MS-DRGs) - Documentation responsibilities of medical and clinical staff - Inpatient Prospective Payment System (IPPS) fundamentals |
| Topic 5: Clinical Knowledge & Disease Processes Application | 20% | - Disease processes across body systems applied to chart review - Medical terminology, anatomy, physiology, pathophysiology - Clinical indicators, lab results, medications, diagnostic findings |
| Topic 6: CDI Program Management & Professional Practice | 15% | - Provider education and training strategies - Program metrics, benchmarks, and performance measurement - Ethics, HIPAA, and professional conduct |
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問題 #29
A hospital had 1,000 inpatient discharges during a reporting period. The sum of the MS-DRG relative weights for those discharges was 1,750. What is the hospital's case mix index (CMI)?
答案：B
解題說明：
Case mix index is calculated by dividing the total MS-DRG relative weights by the number of discharges:
1,750 ÷ 1,000 = 1.75
Therefore, the hospital's CMI is 1.75.
CMI is an aggregate measure representing the average relative resource intensity of the hospital's inpatient population under the MS-DRG system. A higher CMI generally indicates that the hospital treated cases assigned to DRGs with higher average relative weights.
However, CMI should never be interpreted as a pure measure of clinical quality. It can be affected by patient population, service-line composition, surgical volume, transplant activity, documentation completeness, coding accuracy, changes in grouper methodology, and other factors.
CMS specifically publishes hospital CMI data and uses MS-DRG relative weights in the IPPS payment methodology. CMS also maintains FY 2026 case-mix and relative-weight files as part of the final-rule data package.
For CDI program analysis, unexplained CMI changes should trigger investigation rather than an automatic assumption of poor documentation. Service-line and diagnosis-level analysis usually provides a more meaningful interpretation.
CCDS Reference Topics: Case mix index; relative weights; CDI analytics; MS-DRGs; program performance.
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問題 #30
Which statement BEST describes the basic funding mechanism of the Hospital Value-Based Purchasing Program?
答案：A
解題說明：
The Hospital Value-Based Purchasing Program is designed as a budget-neutral program. CMS funds it by reducing participating hospitals' base operating DRG payments by 2% and redistributing the amount through value-based incentive payments based on program performance.
This mechanism is different from the HAC Reduction Program, which imposes a 1% reduction on applicable hospitals in the worst-performing quartile. The two programs should not be confused even though both connect hospital quality performance with Medicare reimbursement.
Hospital VBP performance encompasses multiple quality domains rather than simply determining whether individual HACs occurred. Documentation integrity is relevant because coded diagnoses and clinical information can contribute to risk adjustment and quality-measure calculations.
However, CDI professionals should not seek additional diagnoses merely to affect VBP performance. Their role is to ensure that documented and coded data accurately represent the patient's actual severity, comorbidities, treatments, and outcomes.
For FY 2026, CMS publishes actual Hospital VBP adjustment factors used for eligible discharges and includes those factors within its IPPS final-rule materials.
CCDS Reference Topics: Hospital VBP; IPPS; value-based reimbursement; quality measures; payment methodology.
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問題 #31
A CDI specialist has been asked to present a report to hospital administration that will demonstrate the CDI program's impact over time. Which of the following reports will BEST accomplish this?
答案：B
解題說明：
A line graph showing Risk of Mortality (ROM) and Severity of Illness (SOI) by month provides the strongest evidence of program impact over time because it displays longitudinal trends. Hospital leadership can readily determine whether documented patient complexity and risk profiles are increasing, decreasing, or remaining stable and can correlate those trends with CDI interventions.
The CCDS content outline specifically requires CDI specialists to analyze program trends, use SOI/ROM and other program-performance methodologies, create forecasting data, evaluate hospital performance, and track metrics over time. A line graph is particularly appropriate because time is the independent variable and changes from month to month are immediately visible.
An individual specialist's query rate primarily measures productivity or workflow rather than overall organizational impact. A pie graph of unanswered queries provides a snapshot of one process metric, not longitudinal program effectiveness. A presentation of program goals and objectives communicates strategy but does not demonstrate measurable results.
ROM and SOI also connect CDI work to quality and risk-adjustment outcomes, making them particularly meaningful to senior hospital administration.
CCDS Reference Topics: Healthcare facility CDI program analysis; trend analysis; SOI/ROM; physician and hospital performance.
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問題 #32
A patient with a history of heart failure is admitted with severe dyspnea and bilateral lower-extremity edema.
BNP is 1,000 pg/mL and echocardiography shows an ejection fraction of 25% with left ventricular systolic dysfunction. Which diagnosis should the CDI specialist consider when constructing a clinically supported clarification query?
答案：C
解題說明：
Acute on chronic systolic heart failure is the intended answer. This scenario is adapted from an official ACDIS CCDS sample question, which uses dyspnea, edema, elevated BNP, reduced ejection fraction, and left- ventricular dysfunction to test appropriate heart-failure clarification.
The ejection fraction of 25% and documented left ventricular systolic dysfunction support a systolic phenotype. The patient's significant dyspnea and edema are consistent with acute decompensation superimposed on the established history of heart failure. Together, these findings create a legitimate opportunity to clarify type and acuity.
The CDI specialist must nevertheless avoid diagnosing acute-on-chronic systolic failure independently. The provider determines whether the findings represent acute decompensation, chronic disease, another heart- failure phenotype, or another explanation entirely.
Option A would require evidence supporting both systolic and diastolic dysfunction. Option B fails to capture the apparent acute decompensation. Option D conflicts with the documented systolic dysfunction and reduced EF.
This question illustrates a frequent CCDS theme: translating clinical indicators into a neutral clarification opportunity rather than assigning a diagnosis based solely on test results.
CCDS Reference Topics: Heart-failure acuity and type; ejection fraction; BNP; compliant query development.
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問題 #33
A CDI program reports the following monthly results:
- Provider response rate: 97%
- Provider agreement rate: 84%
- Queries issued after discharge: 38%
- CDI/coder agreement: 96%
Which metric presents the clearest opportunity to improve concurrent CDI workflow?
答案：D
解題說明：
The 38% post-discharge query rate represents the clearest workflow opportunity because a large proportion of clarification is occurring after the concurrent hospitalization period.
A 97% provider response rate reflects strong physician participation, while a 96% CDI/coder agreement rate indicates substantial alignment between concurrent CDI review and final coding. An 84% agreement rate is not inherently problematic because providers must remain free to disagree with a query based on their clinical judgment.
A high retrospective-query percentage can indicate that cases are being reviewed too late, that certain documentation opportunities are not recognized during hospitalization, that discharge documentation introduces unresolved diagnoses, or that staffing/workflow does not adequately prioritize cases before discharge.
A CDI manager should drill further into the metric by service line, query type, day of stay, weekday/weekend discharge, provider group, and reason for retrospective clarification. This analysis helps distinguish unavoidable retrospective queries from remediable process problems.
The objective is not to eliminate every post-discharge query. Some documentation issues become apparent only after final testing, pathology, procedures, or discharge summaries are completed.
CCDS Reference Topics: CDI program metrics; concurrent versus retrospective review; workflow analysis; performance improvement.
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問題 #34
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