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| Section | Weight | Objectives |
|---|---|---|
| Topic 1: Official Guidelines for Coding and Reporting | 14.17% | - Working DRG assignment for multiple diagnoses - Secondary diagnosis assignment - Principal diagnosis assignment - Present on admission indicators - Official Guidelines for Coding and Reporting updates - Hospital-acquired conditions - Coding guidelines for principal diagnosis selection - Discharge dispositions and transfers - AHA Coding Clinic |
| Topic 2: Medical record documentation | 19.17% | - Compliant and noncompliant queries - Documentation requiring clarification - Types of physician queries - Health record elements used for diagnosis and procedure code assignment - Addressing diagnoses without clinical support - ACDIS/AHIMA Guidelines for Achieving a Compliant Query Practice - Translating clinical indicators into compliant queries - When a physician query is warranted - Situations in which queries are not appropriate - Provider role and diagnosis code assignment - Clinical indicators - Physician query formats |
| Topic 3: Healthcare regulations, reimbursement, and documentation requirements related to the IPPS | 12.5% | - Complication/comorbidity (CC) - Coding and billing practices vulnerable to denial - Major complication/comorbidity (MCC) - Medical staff and clinical staff documentation responsibilities - Documentation and medical necessity of setting - Documentation impact on IPPS reimbursement - Medicare Severity Diagnosis Related Groups (MS-DRGs) - Principal diagnosis and medical necessity - Inpatient admission criteria and CMS Two-Midnight Rule - Medicare contractors and their impact on CDI - Case mix index (CMI) - IPPS and its updates and revisions |
| Topic 4: Anatomy and physiology, pathophysiology, pharmacology, and medical terminology | 19.17% | - Clinical indicators and query opportunities by Major Diagnostic Category - Diseases and disorders of the blood and blood-forming organs and immunological disorders - Infectious and parasitic diseases - Diseases and disorders of the digestive system - Diseases and disorders of the skin, subcutaneous tissue, and breast - Diseases and disorders of the musculoskeletal system - Myeloproliferative diseases and disorders and poorly differentiated neoplasms - Standard medical abbreviations - Diseases and disorders of the nervous system - Diseases and disorders of the kidney and urinary tract - Endocrine, nutritional, and metabolic diseases and disorders - Medications as clinical indicators - Diseases and disorders of the respiratory system - Diagnostic tests as clinical indicators - Mental diseases and disorders - Diseases and disorders of the circulatory system - Pharmaceuticals and disease processes - Alcohol/drug use and alcohol/drug-induced organic brain disorders - HIV infections - Diseases and disorders of the hepatobiliary system - Injuries, poisonings, and toxic effects of drugs |
| Topic 5: Professionalism, ethics, and compliance | 9.17% | - CDI department goals beyond reimbursement - Leading queries - Medical record confidentiality - Potential DRG creep - DRG compliance initiatives - Compliance risks indicated by PEPPER |
| Topic 6: Impact of reportable diagnoses on quality of care | 8.33% | - Coded data elements affecting Patient Safety Indicators - Hospital Value-Based Purchasing - Healthcare-associated infections and complication codes - 30-day mortality measures - Mortality reviews and observed/expected ratios - CDI impact on Hospital Value-Based Purchasing - Hospital-Acquired Condition Reduction Program - Documentation and code assignment impact on mortality index - Hospital Readmissions Reduction Program - Patient Safety Indicators - Quality data from record abstraction and claims data - Hospital Inpatient Quality Reporting Program |
| Topic 7: Healthcare facility CDI program analysis | 8.33% | - PEPPER data - Severity of illness and risk of mortality - Physician performance measurement - Basic computer and software application skills - Tracking and trending physician, department, and hospital performance - Hospital-specific financial data - CC/MCC capture - Provider response rates - Hospital Value-Based Purchasing measures - Patient Safety Indicators - CDI specialist productivity metrics - Publicly reported data - CDI program forecasting - Case mix index (CMI) - High-frequency DRGs |
| Topic 8: Communication skills | 9.17% | - Roles and responsibilities of CDI specialists - Effective and non-confrontational physician communication - Reconciling CDI working DRGs with final coded DRGs - Roles and responsibilities of coders working with CDI departments - Verbal versus written physician communication - Educational presentations for healthcare departments and administration - Physician education forms and tools |
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NEW QUESTION # 61
A patient is admitted with pneumonia. On hospital day 3, the patient deteriorates and the physician documents that sepsis developed after admission as a consequence of the pneumonia. Which diagnosis is generally sequenced first?
Answer: B
Explanation:
When a patient is admitted with a localized infection and sepsis develops after admission, the localized infection is generally sequenced as the principal diagnosis, followed by the appropriate sepsis code.
The FY 2026 ICD-10-CM Official Guidelines explicitly distinguish this circumstance from cases in which both the localized infection and sepsis are present on admission. When sepsis develops only after admission, the localized infection responsible for the original hospitalization remains principal.
Therefore, pneumonia is sequenced first in this scenario.
If the patient subsequently develops acute organ dysfunction related to sepsis and the provider documents severe sepsis, additional severe-sepsis and organ-dysfunction codes are assigned as appropriate. The severe- sepsis code cannot itself serve as principal diagnosis.
This question demonstrates why CDI specialists must clarify timing. Simply seeing both "pneumonia" and
"sepsis" in a discharge summary is insufficient to determine correct sequencing when the onset relationship is unclear.
The POA status of sepsis also becomes relevant because documentation indicates that it developed after inpatient admission.
CCDS Reference Topics: Sepsis; pneumonia; sequencing; timing; POA; principal diagnosis.
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NEW QUESTION # 62
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 # 63
When reviewing a patient's chart in the ICU, a CDI specialist determines a query needs to be placed. As the query is being written, the attending physician is leaving the patient's room after completing rounds. Which of the following is the BEST action to take?
Answer: A
Explanation:
A verbal query is the most efficient and appropriate action because the responsible physician is immediately available and the documentation gap has already been identified. CDI practice is not limited to written or electronic queries; verbal clarification is an accepted communication method when conducted compliantly.
The CDI specialist should present the relevant clinical indicators objectively and ask for clarification without directing the physician toward a preferred diagnosis. The conversation should remain clinically focused and must not mention reimbursement, MS-DRG impact, quality scoring, or other incentives.
Importantly, verbal does not mean informal or undocumented. Current query standards require organizations to maintain an auditable query process. Historically, ACDIS/AHIMA guidance has specifically required the essence of verbal queries to be memorialized, including the reason for clarification and relevant clinical indicators. The 2026 ACDIS/AHIMA Guidelines for Achieving a Compliant Query Practice supersede previous versions and remain the current foundational industry standard for query practice.
Waiting unnecessarily could delay clarification and interfere with concurrent CDI workflow. Since the physician is available, direct professional communication is preferable.
CCDS Reference Topics: Communication skills; verbal queries; concurrent CDI review; compliant query practice.
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NEW QUESTION # 64
A patient is admitted with a stage 2 sacral pressure ulcer. During the hospitalization, the ulcer progresses and is documented as stage 3 at the same site. How should the pressure ulcer be reported?
Answer: A
Explanation:
The FY 2026 ICD-10-CM Official Guidelines specifically address a pressure ulcer that progresses to a higher stage during an inpatient admission. Two codes are assigned: one representing the site and stage present on admission and another representing the same ulcer site at the highest stage documented during the hospitalization.
Therefore, this patient's stage 2 sacral pressure ulcer on admission and subsequent progression to stage 3 must both be represented according to the applicable coding instructions.
The distinction is important for both clinical and quality purposes because the record must accurately show what condition existed when the patient entered the hospital and how the wound subsequently evolved.
Coding only the stage 3 ulcer would lose information about its status at admission. Coding only stage 2 would fail to represent the deterioration that occurred during the stay.
Pressure-ulcer staging is also one of the circumstances in which qualified non-provider clinician documentation, such as wound-care nursing documentation, may be used to establish stage when the diagnosis itself is appropriately documented.
For CDI, accurate wound location, stage, progression, and POA documentation are essential because advanced pressure injuries may influence MS-DRG severity and hospital quality reporting.
CCDS Reference Topics: Pressure ulcers; staging; POA; wound-care documentation; Official Guidelines.
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NEW QUESTION # 65
A pregnant patient is admitted at 30 weeks' gestation with acute pyelonephritis complicating pregnancy.
Which general sequencing principle applies?
Answer: B
Explanation:
ICD-10-CM Chapter 15 codes generally have sequencing priority over codes from other chapters when a condition complicates pregnancy, childbirth, or the puerperium.
Therefore, when pyelonephritis complicates pregnancy, the appropriate obstetric complication code is generally sequenced first, with additional code(s) used as instructed to identify the specific infection or organism.
This principle is important because ordinary principal-diagnosis logic can be modified by chapter-specific instructions. CDI specialists working with obstetric cases therefore must determine whether the pregnancy affects management and whether the condition is documented as complicating pregnancy.
The only major exception would be when the provider specifically determines that the pregnancy is incidental to the encounter and the applicable coding requirements for incidental pregnancy are met.
A symptom code does not generally supersede an established definitive diagnosis. Likewise, the fact that an infection could occur outside pregnancy does not negate Chapter 15 sequencing when it is complicating the pregnancy.
Correct gestational-age documentation is also important because an additional code may be required to identify the specific week of gestation.
CCDS Reference Topics: Obstetric coding; Chapter 15; sequencing priority; infection in pregnancy; principal diagnosis.
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NEW QUESTION # 66
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