ACDIS CCDS Cheat Sheet

IPPS Regulations & Reimbursement

12.5% of exam
IPPS & MS-DRG Basics Medicare Program-Integrity Contractors Two-Midnight Rule CC vs MCC

A&P, Pathophysiology & Pharmacology

19.2% of exam
Sepsis Criteria AKI Staging (KDIGO Stage 1) Respiratory Failure Criteria Sepsis-2 vs Sepsis-3 HFrEF vs HFpEF

Medical Record Documentation

19.2% of exam
Query Formats Compliant Query Rules Query Recipients & Timing Concurrent vs Retrospective Query

CDI Program Analysis

8.3% of exam
CDI Program Metrics Response Rate vs Agreement Rate CMI Change vs CDI Credit PEPPER Report

Communication Skills

9.2% of exam
CDI Communication Concepts Working DRG vs Final DRG Nonconfrontational Education DRG Reconciliation

Official Coding Guidelines

14.2% of exam
UHDDS & Sequencing Rules Diagnosis Sequencing Picker Principal Diagnosis Rules Uncertain Diagnosis Exceptions

Professionalism, Ethics & Compliance

9.2% of exam
Ethics & Compliance Terms Leading vs Compliant Query DRG Creep Query Count vs Query Pattern

Quality Impact of Diagnoses

8.3% of exam
Quality & Risk Measures POA Indicator Picker SOI vs ROM HAC-POA vs HAC Reduction Program POA Payment Logic

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 IP

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 IP

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 IP

RA Recovery Auditor finds overpayments
MAC Medicare Administrative Contractor
CERT Error-rate testing contractor
OIG Office of Inspector General

AKI Stage 1 Triggers CL

0.3 up, 1.5x baseline, or low output
Cr +0.3 mg/dL in 48h Cr 1.5-1.9x baseline in 7d Urine <0.5 mL/kg/hr, 6-12h

Sepsis-2 vs Sepsis-3 CL

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 CL

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 CL

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 CL

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) CL

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 CL

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 CL

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 DO

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 DO

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 DO

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 DO

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 DO

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 PR

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 PR

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 CO

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 CO

Principal = reason found after study
Not the admitting diagnosis Complication of care outranks it Ties: either may lead

Diagnosis Sequencing Picker CO

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 CO

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 ET

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 QU

Y and W pay; N and U don't
Y: present on admission W: undetermined, still pays N: not present, no pay U: insufficient documentation, no pay

HAC-POA vs HAC Reduction Program QU

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 QU

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 QU

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 QU

1 is minor, 4 is extreme
SOI: how sick now ROM: risk of death Scores can diverge by case

SOI vs ROM QU

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

ACDIS Certified Clinical Documentation Specialist (CCDS)

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