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| Section | Weight | Objectives |
|---|---|---|
| Healthcare facility CDI program analysis | 8.33% | - Hospital Value-Based Purchasing measures - High-frequency DRGs - CDI specialist productivity metrics - Severity of illness and risk of mortality - Physician performance measurement - CC/MCC capture - Case mix index (CMI) - Tracking and trending physician, department, and hospital performance - Hospital-specific financial data - Provider response rates - Patient Safety Indicators - PEPPER data - Basic computer and software application skills - Publicly reported data - CDI program forecasting |
| Medical record documentation | 19.17% | - ACDIS/AHIMA Guidelines for Achieving a Compliant Query Practice - Addressing diagnoses without clinical support - Translating clinical indicators into compliant queries - Provider role and diagnosis code assignment - Clinical indicators - Situations in which queries are not appropriate - Physician query formats - Health record elements used for diagnosis and procedure code assignment - When a physician query is warranted - Compliant and noncompliant queries - Types of physician queries - Documentation requiring clarification |
| Communication skills | 9.17% | - Educational presentations for healthcare departments and administration - Reconciling CDI working DRGs with final coded DRGs - Roles and responsibilities of coders working with CDI departments - Roles and responsibilities of CDI specialists - Verbal versus written physician communication - Effective and non-confrontational physician communication - Physician education forms and tools |
| Healthcare regulations, reimbursement, and documentation requirements related to the IPPS | 12.5% | - IPPS and its updates and revisions - Case mix index (CMI) - Coding and billing practices vulnerable to denial - Principal diagnosis and medical necessity - Complication/comorbidity (CC) - Medicare Severity Diagnosis Related Groups (MS-DRGs) - Major complication/comorbidity (MCC) - Medicare contractors and their impact on CDI - Medical staff and clinical staff documentation responsibilities - Documentation impact on IPPS reimbursement - Documentation and medical necessity of setting - Inpatient admission criteria and CMS Two-Midnight Rule |
| Official Guidelines for Coding and Reporting | 14.17% | - Working DRG assignment for multiple diagnoses - AHA Coding Clinic - Principal diagnosis assignment - Hospital-acquired conditions - Present on admission indicators - Coding guidelines for principal diagnosis selection - Discharge dispositions and transfers - Official Guidelines for Coding and Reporting updates - Secondary diagnosis assignment |
| Professionalism, ethics, and compliance | 9.17% | - Potential DRG creep - Compliance risks indicated by PEPPER - CDI department goals beyond reimbursement - Medical record confidentiality - Leading queries - DRG compliance initiatives |
| Impact of reportable diagnoses on quality of care | 8.33% | - Hospital Value-Based Purchasing - Mortality reviews and observed/expected ratios - Hospital Readmissions Reduction Program - Documentation and code assignment impact on mortality index - Quality data from record abstraction and claims data - CDI impact on Hospital Value-Based Purchasing - 30-day mortality measures - Patient Safety Indicators - Coded data elements affecting Patient Safety Indicators - Healthcare-associated infections and complication codes - Hospital Inpatient Quality Reporting Program - Hospital-Acquired Condition Reduction Program |
| Anatomy and physiology, pathophysiology, pharmacology, and medical terminology | 19.17% | - Diagnostic tests as clinical indicators - Diseases and disorders of the circulatory system - Standard medical abbreviations - Infectious and parasitic diseases - Injuries, poisonings, and toxic effects of drugs - Mental diseases and disorders - Diseases and disorders of the musculoskeletal system - Myeloproliferative diseases and disorders and poorly differentiated neoplasms - Diseases and disorders of the skin, subcutaneous tissue, and breast - Diseases and disorders of the digestive system - Pharmaceuticals and disease processes - Diseases and disorders of the kidney and urinary tract - Diseases and disorders of the respiratory system - HIV infections - Diseases and disorders of the blood and blood-forming organs and immunological disorders - Clinical indicators and query opportunities by Major Diagnostic Category - Diseases and disorders of the nervous system - Alcohol/drug use and alcohol/drug-induced organic brain disorders - Medications as clinical indicators - Diseases and disorders of the hepatobiliary system - Endocrine, nutritional, and metabolic diseases and disorders |
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質問 # 126
A patient with active breast cancer is admitted solely to receive a scheduled cycle of antineoplastic chemotherapy. No complication or acute disease process is responsible for the admission. Which diagnosis is generally sequenced first?
正解：A
解説：
When an inpatient encounter is solely for administration of chemotherapy, the encounter-for-chemotherapy code is generally sequenced first, followed by the code identifying the malignancy being treated.
This represents an important exception to the usual expectation that the underlying disease is the principal diagnosis. The circumstances of admission are specifically treatment administration rather than management of an acute complication of the malignancy.
If, however, the patient were admitted because of a complication-such as chemotherapy-induced neutropenic fever, dehydration, anemia, or another adverse effect-the principal-diagnosis analysis would follow the applicable guideline for that condition rather than automatically using the chemotherapy encounter code.
Similarly, if chemotherapy were administered incidentally during a hospitalization principally required for another condition, the encounter-for-chemotherapy code would not displace the actual principal diagnosis.
CDI professionals should therefore distinguish planned treatment encounters from admissions caused by complications of treatment or malignancy.
Clear documentation regarding the reason for admission, cancer site, treatment intent, metastatic disease, and complications helps support proper sequencing and accurate oncology data.
CCDS Reference Topics: Antineoplastic chemotherapy; encounter codes; neoplasm sequencing; principal diagnosis; oncology documentation.
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質問 # 127
A patient is admitted with nausea, confusion, and generalized weakness. Laboratory testing shows a serum sodium level of 119 mEq/L. The patient receives hypertonic saline and frequent serum sodium monitoring.
The physician documents "electrolyte disturbance." Which condition is the MOST appropriate clarification opportunity?
正解：C
解説：
The clinical findings strongly support clarification of hyponatremia. A serum sodium concentration of 119 mEq/L represents substantial reduction below the usual reference range, and neurologic manifestations such as confusion are consistent with clinically significant hyponatremia. Administration of hypertonic saline and frequent sodium monitoring further demonstrate that the electrolyte abnormality is clinically important.
The CDI specialist should not independently assign the diagnosis based solely on the laboratory result.
Instead, the abnormal sodium level, neurologic symptoms, and targeted therapy provide an appropriate clinical basis for a neutral provider query.
Hypernatremia represents elevated serum sodium and therefore contradicts the laboratory finding.
Hyperkalemia relates to potassium rather than sodium. Metabolic alkalosis is an acid-base disturbance requiring supporting blood-gas and chemistry findings and is not established by the information provided.
Further specificity may also matter. Depending on the clinical record, the physician may determine that the hyponatremia is related to SIADH, volume depletion, medication use, heart failure, cirrhosis, or another etiology.
The CCDS role is to recognize the clinical significance of laboratory abnormalities and obtain clinically meaningful provider documentation rather than simply translating abnormal values into diagnoses.
CCDS Reference Topics: Electrolyte abnormalities; hyponatremia; laboratory interpretation; clinical indicators; documentation clarification.
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質問 # 128
A neurologist documents acute cerebral infarction. A qualified stroke nurse records the NIH Stroke Scale score in the medical record. Which statement is MOST accurate?
正解：B
解説：
ICD-10-CM permits the NIH Stroke Scale score to be reported from documentation by an appropriate clinician other than the provider responsible for establishing the diagnosis. The underlying stroke diagnosis itself must be appropriately documented by the provider.
This is similar to other specified exceptions such as BMI, pressure-ulcer stage, coma scale values, and certain additional clinical elements for which qualified non-provider documentation may support code assignment.
The exception does not mean that a stroke nurse can independently establish cerebral infarction for coding.
Rather, once the provider has documented the stroke, the nurse's formal NIHSS assessment can supply the standardized severity measurement.
This approach recognizes that specially trained clinical professionals routinely collect and document these structured measurements as part of patient care.
If multiple NIHSS values are documented, the applicable coding instructions and timing requirements should be followed rather than simply selecting the highest score because it produces a different code.
For CDI professionals, awareness of these non-provider documentation exceptions prevents unnecessary physician queries while ensuring that important severity information is not lost.
CCDS Reference Topics: NIH Stroke Scale; cerebral infarction; non-provider documentation; coding exceptions; stroke severity.
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質問 # 129
A CDI manager notes that the physician query response rate is 98%, but only 55% of queries are answered before discharge. Which metric should receive the MOST immediate workflow analysis?
正解：A
解説：
The overall response rate is excellent at 98%, but the fact that only 55% of queries are resolved before discharge indicates a meaningful concurrent-workflow issue.
Concurrent CDI is most effective when clarification occurs while the patient remains hospitalized and the physician has immediate access to the clinical context. Delayed responses can contribute to retrospective work, final-bill holds, coding delays, and administrative escalation.
The CDI manager should determine whether delays cluster by provider, specialty, query type, unit, day of week, discharge timing, or electronic-query process. Other factors may include insufficient notification, physician workflow, poor escalation protocols, or queries being issued too late in the stay.
CMI and MCC volume do not directly measure response timeliness and should not substitute for analysis of the actual operational problem.
Importantly, programs should not pressure physicians into rapid but clinically superficial responses. Query timing initiatives must preserve thoughtful provider judgment and compliant communication.
ACDIS identifies medical-record review, communication, query technique, and data-mining/reporting functions among core CCDS competencies.
CCDS Reference Topics: Query timeliness; concurrent CDI; physician engagement; workflow analysis; program metrics.
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質問 # 130
At discharge, the physician documents, "Possible gram-negative pneumonia." No later documentation rules out the condition. How should the diagnosis generally be handled for an inpatient admission?
正解：C
解説：
In the inpatient hospital setting, an uncertain diagnosis documented at discharge using terminology such as possible, probable, suspected, likely, questionable, compatible with, or consistent with may generally be coded as though the condition existed or was established.
Therefore, "possible gram-negative pneumonia" may be coded in accordance with the inpatient uncertain- diagnosis guideline when it remains the final diagnostic conclusion.
The rationale is that inpatient diagnostic evaluation and treatment frequently occur before absolute confirmation is available, and the patient may have been managed as though the suspected disease were present.
This rule is materially different from outpatient coding, where uncertain diagnoses are generally not coded as established and the documented signs, symptoms, or confirmed conditions are reported instead.
The presence of the uncertain terminology alone does not mandate a query. A query would be appropriate if documentation is contradictory, if the diagnosis is clinically unsupported, or if another documentation issue prevents correct code assignment.
CDI specialists need to recognize this inpatient-specific rule because unnecessary queries for "possible" or
"probable" diagnoses can create physician burden without improving coding accuracy.
CCDS Reference Topics: Uncertain inpatient diagnoses; discharge documentation; pneumonia; inpatient versus outpatient coding.
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質問 # 131
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