IPPS Regulations & Reimbursement
12.5%of exam
A&P, Pathophysiology & Pharmacology
19.2%of exam
Medical Record Documentation
19.2%of exam
CDI Program Analysis
8.3%of exam
Communication Skills
9.2%of exam
Official Coding Guidelines
14.2%of exam
UHDDS & Sequencing RulesDiagnosis Sequencing PickerPrincipal Diagnosis RulesUncertain Diagnosis Exceptions
Professionalism, Ethics & Compliance
9.2%of exam
Quality Impact of Diagnoses
8.3%of exam
Quick Facts
- Exam
- CCDS
- Credential
- Clinical Documentation Specialist
- Items
- 140 (120 scored)
- Time
- 3 hours
- Pass
- 88 of 120
- Retake wait
- 90 days
- Recert
- 2 yrs / 30 CEUs
- Handbook
- May 2024
CC vs MCC
CC
- Complication or comorbidity
- Standard severity add-on
- Lower MS-DRG payment bump
MCC
- Major complication or comorbidity
- Highest severity add-on
- Bigger MS-DRG payment bump
MCC outweighs CC
IPPS & MS-DRG Basics
- MS-DRG
- Fixed payment per DRG
- CC
- Complication or comorbidity add-on
- MCC
- Major CC, higher severity tier
- CMI
- Average MS-DRG relative weight
- IPPS Update
- Annual rule, effective Oct 1
- Two-Midnight Rule
- CFR 412.3(d) inpatient test
- Grouper
- Software assigning the MS-DRG
- Relative Weight
- DRG's payment multiplier value
Medicare Program-Integrity Contractors
- RA
- Recovery Auditor finds overpayments
- MAC
- Medicare Administrative Contractor
- CERT
- Error-rate testing contractor
- OIG
- Office of Inspector General
AKI Stage 1 Triggers
0.3 up, 1.5x baseline, or low output
Cr +0.3 mg/dL in 48hCr 1.5-1.9x baseline in 7dUrine <0.5 mL/kg/hr, 6-12h
Sepsis-2 vs Sepsis-3
Sepsis-2
- SIRS-based definition
- Two or more criteria
- Older, still-used standard
Sepsis-3
- SOFA-based definition
- Organ dysfunction focus
- Increasingly payer-preferred
SIRS vs organ dysfunction
Clinical Validation Trigger Picker
- Infection, SOFA up 2+→Sepsis-3 criteria met(Organ dysfunction, SIRS not required)
- SIRS present, no infection→SIRS only, not sepsis(Check trauma or pancreatitis)
- Creatinine up 0.3 in 48h→AKI Stage 1(KDIGO criterion)
- PaO2 under 60→Hypoxemic respiratory failure(Room air reading)
- PaCO2 over 50, pH low→Hypercapnic respiratory failure(Acute respiratory acidosis)
- Two of six ASPEN traits→Malnutrition diagnosis supported(Any severity context applies)
Sepsis Criteria
- SIRS
- 2+ abnormal vitals or labs
- Sepsis-2
- SIRS plus infection source
- Sepsis-3
- Infection plus rising SOFA
- SOFA
- Organ-dysfunction severity score
- Septic Shock
- Sepsis with persistent hypotension
HFrEF vs HFpEF
HFrEF
- EF 40% or less
- Reduced pumping function
- Classic 'weak heart'
HFpEF
- EF 50% or more
- Stiff, poorly relaxing ventricle
- Near-normal ejection fraction
Low EF vs normal EF
AKI Staging (KDIGO Stage 1)
- Cr Trigger
- Up 0.3 mg/dL in 48h
- Baseline Trigger
- 1.5-1.9x baseline within 7 days
- Urine Trigger
- Under 0.5 mL/kg/hr, 6-12h
- Any One
- Single criterion alone is enough
Respiratory Failure Criteria
- Hypoxemic
- PaO2 under 60, room air
- P/F Ratio
- Under 300 on oxygen support
- Hypercapnic
- PaCO2 over 50, pH low
- Support Signs
- Oxygen or ventilator assistance used
Other Clinical Indicators
- Malnutrition
- 2 of 6 ASPEN traits
- HFrEF
- EF 40% or less
- HFpEF
- EF 50% or more
- Metabolic encephalopathy
- Systemic cause, diffuse dysfunction
- Medication Clue
- Drug order prompts a query
Concurrent vs Retrospective Query
Concurrent
- During the admission
- Provider can still answer
- Real-time chart review
Retrospective
- After discharge occurs
- Works from closed record
- Needs a response window
Before discharge vs after
Query Format Picker
- New diagnosis suspected→Open-ended or multiple-choice(Never yes/no)
- Confirm POA status→Yes/no query(Offer unable to determine)
- Confirm existing finding→Yes/no query(e.g., pathology report)
- Link two conditions→Yes/no query(Cause-and-effect only)
- Several valid diagnoses fit→Multiple-choice query(Add 'other' and 'undetermined')
- Urgent, time-sensitive question→Verbal query(Still log and chart)
- Complex or disputed issue→Written query(Preserves clear record trail)
- Prior encounter finding only→Query only with current trigger(Else record mining)
Query Formats
- Open-Ended
- Free-text provider explanation
- Multiple-Choice
- Reasonable options plus 'other'
- Yes/No
- Confirms one existing fact
- Verbal
- Spoken, but still logged
- Written
- Formal, preserves the record trail
Compliant Query Rules
- Nonleading
- No hint toward one answer
- Clinical Indicators
- Must be cited and sourced
- No Reimbursement Talk
- Excluded from query wording
- UTD Option
- Required in POA yes/no queries
- Record Mining
- Querying without current trigger
- Multiple Queries
- Pattern matters, not raw count
Query Recipients & Timing
- Provider
- Legally accountable diagnosing clinician
- Consulting Specialist
- Valid within their own findings
- Concurrent Query
- Sent before patient discharge
- Retrospective Query
- Sent from the closed record
Response Rate vs Agreement Rate
Response Rate
- Provider answers at all
- Engagement measure
- Low value: unresponsive providers
Agreement Rate
- Answer supports the diagnosis
- Accuracy measure
- Low value: frequent disagreement
Answered vs agreed
CDI Program Metrics
- Response Rate
- Provider answers query at all
- Agreement Rate
- Answer supports the suspected diagnosis
- CMI Trend
- Watch case-mix shifts too
- CC/MCC Capture
- Documentation completeness metric
- PEPPER
- CMS payment-pattern percentile report
- High-Frequency DRG
- Small error, large total exposure
CDI Communication Concepts
- Working DRG
- CDI's concurrent, in-progress estimate
- Final Coded DRG
- Coder's closed-record assignment
- Reconciliation
- Compares working DRG to final
- Nonconfrontational Education
- Frames queries around data quality
- CDI vs Coder
- Concurrent versus post-discharge review
UHDDS Sequencing Rule
Principal = reason found after study
Not the admitting diagnosisComplication of care outranks itTies: either may lead
Diagnosis Sequencing Picker
- Chiefly responsible after study→Principal diagnosis(Not the admitting diagnosis)
- Admission caused by complication→Complication as principal(Outranks underlying condition)
- Two diagnoses equally qualify→Either may sequence first(Unless index or tabular directs)
- Affects treatment, stay, or monitoring→Code as secondary diagnosis(UHDDS other diagnoses rule)
- Still uncertain at discharge→Code as if established(Except HIV, COVID-19, Zika, J09/J10)
- Outpatient, still uncertain→Code to highest certainty(Signs and symptoms only)
UHDDS & Sequencing Rules
- Principal Diagnosis
- Chief reason, found after study
- Other Diagnoses
- Affect treatment, stay, or monitoring
- Uncertain Diagnosis
- Coded as if established, inpatient
- UD Exceptions
- HIV, COVID-19, Zika, J09/J10 flu
- Complication of Care
- Sequences as the principal diagnosis
- Equal Diagnoses
- Either may sequence first
- Coding Clinic
- AHA's official coding advice
Ethics & Compliance Terms
- Leading Query
- Implies the desired diagnosis
- DRG Creep
- Unsupported drift to higher DRGs
- Code of Ethics
- Puts accuracy over reimbursement
- Confidentiality
- Only access assigned records
- Denial Defense
- Validate indicators before appealing
POA Payment Logic
Y and W pay; N and U don't
Y: present on admissionW: undetermined, still paysN: not present, no payU: insufficient documentation, no pay
HAC-POA vs HAC Reduction Program
HAC-POA Provision
- Per-condition CC/MCC hit
- Triggered by POA N or U
- Payment-level, case-specific rule
HAC Reduction Program
- Hospital-level 1% payment cut
- Worst quartile, PSI 90 plus NHSN
- Program-level, hospital-wide rule
Condition-level vs hospital-level
POA Indicator Picker
- Condition present at admission→Y(CC/MCC payment allowed)
- Not present at admission→N(No CC/MCC payment)
- Documentation is insufficient→U(Treated like N)
- Provider clinically undetermined→W(Treated like Y)
Quality & Risk Measures
- PSI 90
- PSIs 03, 06, and 08-15
- HAC-POA Provision
- Blocks CC/MCC for N/U
- HAC Reduction Program
- 1% cut, worst total-score quartile
- SOI
- Severity of illness, now
- ROM
- Risk of mortality, 1-4 scale
- Readmission/Mortality
- Risk-adjusted using coded data
SOI ROM Scale
1 is minor, 4 is extreme
SOI: how sick nowROM: risk of deathScores can diverge by case
SOI vs ROM
SOI
- Severity of illness
- How sick right now
- Scored 1 to 4
ROM
- Risk of mortality
- Chance of dying
- Also scored 1 to 4
Sick now vs death risk
Common Traps
Leading vs Compliant Query
States a conclusion ≠ Compliant cites clinical indicators
SIRS vs Sepsis
SIRS is vitals plus WBC ≠ Sepsis needs infection source too
Working DRG vs Final DRG
Working is CDI's estimate ≠ Final is coder's closed-record DRG
Query Count vs Query Pattern
Multiple queries aren't automatically wrong ≠ Repeated pressure toward one answer is
CMI Change vs CDI Credit
CMI can shift from case mix ≠ Check CC/MCC capture, then credit
Unable to Determine vs Uncertain
UTD means data are insufficient ≠ Differs from possible or probable
Last Minute
- 1.140 items: 120 scored, 20 pretest
- 2.3-hour exam; pass 88 of 120
- 3.90-day wait after any failed attempt
- 4.Recert every 2 years, 30 CEUs
- 5.Y or W pays CC/MCC
- 6.N or U blocks CC/MCC
- 7.Never yes/no for new diagnosis
- 8.Compliant query cites indicators, not conclusions
- 9.Principal diagnosis set after study
- 10.PSI 90 = PSIs 03, 06, 08-15
- 11.Sepsis-3 needs rising SOFA score
- 12.Record mining needs a current trigger
- 13.Unsupported upcoding draws OIG audits
- 14.Multiple queries: pattern matters, not count
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