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| Section | Weight | Objectives |
|---|---|---|
| Topic 1: Professionalism, ethics, and compliance | 9.17% | - Leading queries - Potential DRG creep - CDI department goals beyond reimbursement - Compliance risks indicated by PEPPER - DRG compliance initiatives - Medical record confidentiality |
| Topic 2: Healthcare facility CDI program analysis | 8.33% | - CDI specialist productivity metrics - PEPPER data - CDI program forecasting - Case mix index (CMI) - Patient Safety Indicators - Physician performance measurement - Provider response rates - Hospital Value-Based Purchasing measures - Hospital-specific financial data - Publicly reported data - Severity of illness and risk of mortality - High-frequency DRGs - Tracking and trending physician, department, and hospital performance - Basic computer and software application skills - CC/MCC capture |
| Topic 3: Healthcare regulations, reimbursement, and documentation requirements related to the IPPS | 12.5% | - 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 - Medicare Severity Diagnosis Related Groups (MS-DRGs) - Documentation and medical necessity of setting - Complication/comorbidity (CC) - Coding and billing practices vulnerable to denial - Major complication/comorbidity (MCC) - Principal diagnosis and medical necessity - Medical staff and clinical staff documentation responsibilities - Documentation impact on IPPS reimbursement |
| Topic 4: Anatomy and physiology, pathophysiology, pharmacology, and medical terminology | 19.17% | - Standard medical abbreviations - Injuries, poisonings, and toxic effects of drugs - Diseases and disorders of the digestive system - Diseases and disorders of the blood and blood-forming organs and immunological disorders - Diseases and disorders of the hepatobiliary system - Diseases and disorders of the skin, subcutaneous tissue, and breast - Diseases and disorders of the circulatory system - Clinical indicators and query opportunities by Major Diagnostic Category - Diseases and disorders of the nervous system - Medications as clinical indicators - Myeloproliferative diseases and disorders and poorly differentiated neoplasms - Alcohol/drug use and alcohol/drug-induced organic brain disorders - Diseases and disorders of the kidney and urinary tract - Mental diseases and disorders - Pharmaceuticals and disease processes - Diseases and disorders of the respiratory system - Endocrine, nutritional, and metabolic diseases and disorders - Diagnostic tests as clinical indicators - Infectious and parasitic diseases - Diseases and disorders of the musculoskeletal system - HIV infections |
| Topic 5: Impact of reportable diagnoses on quality of care | 8.33% | - Hospital Readmissions Reduction Program - Patient Safety Indicators - Hospital Value-Based Purchasing - Mortality reviews and observed/expected ratios - Quality data from record abstraction and claims data - Hospital Inpatient Quality Reporting Program - 30-day mortality measures - Documentation and code assignment impact on mortality index - Hospital-Acquired Condition Reduction Program - Healthcare-associated infections and complication codes - Coded data elements affecting Patient Safety Indicators - CDI impact on Hospital Value-Based Purchasing |
| Topic 6: Communication skills | 9.17% | - Verbal versus written physician communication - Educational presentations for healthcare departments and administration - Physician education forms and tools - Roles and responsibilities of coders working with CDI departments - Reconciling CDI working DRGs with final coded DRGs - Effective and non-confrontational physician communication - Roles and responsibilities of CDI specialists |
| Topic 7: Medical record documentation | 19.17% | - ACDIS/AHIMA Guidelines for Achieving a Compliant Query Practice - Addressing diagnoses without clinical support - Clinical indicators - Types of physician queries - When a physician query is warranted - Health record elements used for diagnosis and procedure code assignment - Situations in which queries are not appropriate - Compliant and noncompliant queries - Documentation requiring clarification - Translating clinical indicators into compliant queries - Provider role and diagnosis code assignment - Physician query formats |
| Topic 8: Official Guidelines for Coding and Reporting | 14.17% | - Coding guidelines for principal diagnosis selection - Official Guidelines for Coding and Reporting updates - Principal diagnosis assignment - Discharge dispositions and transfers - Working DRG assignment for multiple diagnoses - AHA Coding Clinic - Secondary diagnosis assignment - Hospital-acquired conditions - Present on admission indicators |
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NEW QUESTION # 101
A patient is admitted with a stage 4 pressure ulcer of the right heel. The physician documents the pressure- ulcer diagnosis and location. The wound-care nurse documents stage 4. Which statement is MOST accurate?
Answer: A
Explanation:
Pressure-ulcer staging is one of the recognized circumstances in which ICD-10-CM permits the relevant clinical detail to be obtained from documentation by an appropriate non-provider clinician, such as a qualified wound-care nurse.
The provider establishes the medical diagnosis, while the wound-care clinician's specialized assessment may support the stage assignment. This distinction allows coding to reflect the expertise of clinicians who directly assess the wound without requiring physicians to duplicate every technical staging statement.
Option C is too broad. The exception permitting stage documentation from another clinician does not grant non-provider documentation unrestricted authority to establish all reportable medical diagnoses.
Pressure-ulcer stage is highly relevant because ICD-10-CM pressure-ulcer codes incorporate both anatomical site and stage. It can also have substantial implications for severity reporting, POA assessment, CMS HAC policy, nursing care, quality review, and risk adjustment.
When different clinicians document conflicting stages, clarification should be pursued rather than selecting the most severe value.
CCDS candidates should understand the distinction between provider-established diagnoses and specific coding elements that ICD-10-CM permits to originate from other qualified professionals.
CCDS Reference Topics: Pressure ulcers; wound staging; non-provider documentation; coding exceptions.
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NEW QUESTION # 102
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?
Answer: A
Explanation:
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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NEW QUESTION # 103
Documentation indicates an excisional debridement was performed without further specification. The CDI specialist should query to clarify which of the following?
Answer: D
Explanation:
The most critical missing element is the depth or level of tissue actually debrided. Documentation of an excisional debridement should identify whether tissue removed included skin, subcutaneous tissue, fascia, muscle, bone, or another anatomical layer. The level removed is fundamental to accurate procedural classification and coding.
CMS wound-care documentation standards similarly emphasize that the medical record should describe the type and depth of tissue removed. Merely knowing that an excisional debridement occurred does not establish the anatomical level of the procedure.
The instrument may provide useful procedural context-for example, scalpel, scissors, curette, or other technique-but the instrument alone does not identify the deepest tissue excised. Wound size can be important for clinical care and certain coding systems, but it does not replace documentation of the tissue level removed. The identity of the person performing the procedure is also part of procedural documentation but does not answer the principal coding-specific deficiency in this scenario.
A CDI query should therefore seek the deepest tissue level actually excised rather than infer it from the wound's overall depth.
CCDS Reference Topics: Medical record documentation; ICD-10-PCS/procedure documentation; debridement specificity.
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NEW QUESTION # 104
A patient is admitted with sepsis due to an E. coli urinary tract infection. The provider also documents acute kidney injury due to the sepsis and "severe sepsis without septic shock." Which sequencing is most appropriate?
Answer: D
Explanation:
When severe sepsis is documented, coding requires the underlying systemic infection first, followed by the appropriate severe-sepsis code and additional code(s) for the acute organ dysfunction. Therefore, the sepsis code is sequenced first, followed by the severe-sepsis code and acute kidney injury.
The FY 2026 ICD-10-CM Official Guidelines state that severe sepsis requires at least two codes: one for the underlying systemic infection and another from subcategory R65.2-. Additional codes identify associated acute organ dysfunction. A code from R65.2- cannot serve as the principal diagnosis.
The UTI identifies the localized source but does not replace the systemic infection as principal diagnosis when sepsis is the condition chiefly responsible for admission. Likewise, the AKI is a manifestation of the severe systemic process and is not sequenced before the sepsis in this scenario.
For CDI specialists, the essential documentation element is the relationship between sepsis and the acute organ dysfunction. Organ dysfunction alone does not automatically permit severe-sepsis coding; provider documentation must establish the association when it is not inherent.
CCDS Reference Topics: Sepsis; severe sepsis; organ dysfunction; sequencing; principal diagnosis.
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NEW QUESTION # 105
A physician documents "postoperative urinary retention" after surgery. The patient required temporary catheterization, but the surgeon indicates that urinary retention is a common expected consequence of anesthesia in this case. What should the CDI specialist do before treating the condition as a postoperative complication?
Answer: A
Explanation:
The CDI specialist should clarify whether the urinary retention represents an actual postoperative complication or an expected consequence of surgery/anesthesia.
ICD-10-CM does not classify every condition that occurs after medical or surgical care as a complication.
Provider documentation must establish the appropriate relationship when required, and the condition should represent more than an expected physiologic consequence.
Temporary urinary retention can occur after anesthesia, opioid administration, pelvic surgery, or immobilization. Its appearance following surgery therefore does not automatically establish a complication of care.
The query should objectively present the postoperative urinary retention, catheterization, duration, treatment, and any surgeon or anesthesia documentation indicating whether the event was expected. The provider can then characterize the condition appropriately.
Automatically assigning a device-related complication would introduce another unsupported causal relationship. CDI also cannot delete the documented condition simply because it may be expected.
This distinction is important because complication codes can influence MS-DRG assignment, quality reporting, patient-safety analyses, and public performance information. Accurate characterization is therefore essential.
CCDS Reference Topics: Complications of care; postoperative urinary retention; cause-and-effect relationship; clinical clarification.
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NEW QUESTION # 106
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