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| Section | Weight | Objectives |
|---|---|---|
| Topic 1: Anatomy and physiology, pathophysiology, pharmacology, and medical terminology | 19.17% | - Myeloproliferative diseases and disorders and poorly differentiated neoplasms - Clinical indicators and query opportunities by Major Diagnostic Category - Pharmaceuticals and disease processes - Diseases and disorders of the hepatobiliary system - Alcohol/drug use and alcohol/drug-induced organic brain disorders - Injuries, poisonings, and toxic effects of drugs - Standard medical abbreviations - Diseases and disorders of the digestive system - Diseases and disorders of the respiratory system - Diseases and disorders of the nervous system - HIV infections - Diseases and disorders of the blood and blood-forming organs and immunological disorders - Diseases and disorders of the kidney and urinary tract - Diseases and disorders of the circulatory system - Diagnostic tests as clinical indicators - Infectious and parasitic diseases - Diseases and disorders of the musculoskeletal system - Diseases and disorders of the skin, subcutaneous tissue, and breast - Endocrine, nutritional, and metabolic diseases and disorders - Mental diseases and disorders - Medications as clinical indicators |
| Topic 2: Official Guidelines for Coding and Reporting | 14.17% | - Principal diagnosis assignment - Present on admission indicators - Secondary diagnosis assignment - AHA Coding Clinic - Discharge dispositions and transfers - Hospital-acquired conditions - Official Guidelines for Coding and Reporting updates - Coding guidelines for principal diagnosis selection - Working DRG assignment for multiple diagnoses |
| Topic 3: Medical record documentation | 19.17% | - When a physician query is warranted - Compliant and noncompliant queries - Addressing diagnoses without clinical support - Situations in which queries are not appropriate - ACDIS/AHIMA Guidelines for Achieving a Compliant Query Practice - Translating clinical indicators into compliant queries - Provider role and diagnosis code assignment - Health record elements used for diagnosis and procedure code assignment - Physician query formats - Documentation requiring clarification - Clinical indicators - Types of physician queries |
| Topic 4: Impact of reportable diagnoses on quality of care | 8.33% | - Patient Safety Indicators - Quality data from record abstraction and claims data - Documentation and code assignment impact on mortality index - 30-day mortality measures - Hospital Value-Based Purchasing - Hospital Inpatient Quality Reporting Program - Healthcare-associated infections and complication codes - Coded data elements affecting Patient Safety Indicators - Hospital-Acquired Condition Reduction Program - Hospital Readmissions Reduction Program - CDI impact on Hospital Value-Based Purchasing - Mortality reviews and observed/expected ratios |
| Topic 5: Healthcare facility CDI program analysis | 8.33% | - Case mix index (CMI) - Patient Safety Indicators - PEPPER data - CDI program forecasting - Severity of illness and risk of mortality - Publicly reported data - Hospital Value-Based Purchasing measures - Provider response rates - Basic computer and software application skills - High-frequency DRGs - CC/MCC capture - CDI specialist productivity metrics - Physician performance measurement - Hospital-specific financial data - Tracking and trending physician, department, and hospital performance |
| Topic 6: Healthcare regulations, reimbursement, and documentation requirements related to the IPPS | 12.5% | - Case mix index (CMI) - Coding and billing practices vulnerable to denial - Principal diagnosis and medical necessity - Complication/comorbidity (CC) - Inpatient admission criteria and CMS Two-Midnight Rule - IPPS and its updates and revisions - Major complication/comorbidity (MCC) - Medicare contractors and their impact on CDI - Medicare Severity Diagnosis Related Groups (MS-DRGs) - Medical staff and clinical staff documentation responsibilities - Documentation and medical necessity of setting - Documentation impact on IPPS reimbursement |
| Topic 7: Professionalism, ethics, and compliance | 9.17% | - Leading queries - CDI department goals beyond reimbursement - Medical record confidentiality - Potential DRG creep - DRG compliance initiatives - Compliance risks indicated by PEPPER |
| Topic 8: Communication skills | 9.17% | - Reconciling CDI working DRGs with final coded DRGs - Physician education forms and tools - Effective and non-confrontational physician communication - Roles and responsibilities of CDI specialists - Educational presentations for healthcare departments and administration - Roles and responsibilities of coders working with CDI departments - Verbal versus written physician communication |
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NEW QUESTION # 98
An 82-year-old patient with a urinary infection develops an acute fluctuating disturbance in attention, disorganized thinking, and altered level of consciousness. The family states the patient was cognitively normal three days earlier. Which condition is MOST consistent with this presentation?
Answer: D
Explanation:
The presentation is most consistent with delirium, an acute and fluctuating disturbance in attention, awareness, and cognition that frequently develops in medically ill hospitalized patients.
The abrupt onset over several days and fluctuating cognitive state distinguish delirium from most forms of dementia, which generally develop progressively over months or years. Infection, medications, metabolic abnormalities, dehydration, hypoxia, and organ dysfunction are common precipitants.
A urinary infection may be a contributing clinical factor, but CDI should not automatically establish a cause- and-effect relationship between infection and delirium unless supported by provider documentation.
The CDI specialist should also recognize that terms such as "altered mental status" are symptoms rather than equivalent substitutes for a more specific diagnosis. When the clinical record contains sufficient indicators and the provider has documented only nonspecific mental-status terminology, a query may be warranted.
Intellectual disability represents a developmental condition rather than an acute change in cognition. A persistent vegetative state represents profound and persistent impairment of consciousness and is inconsistent with the described fluctuating presentation.
CCDS Reference Topics: Delirium; altered mental status; cognitive disorders; clinical indicators; documentation specificity.
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NEW QUESTION # 99
A physician documents acute kidney injury. The patient's creatinine is 0.8 mg/dL on admission, 0.9 mg/dL the following day, and 0.8 mg/dL at discharge. Urine output remains normal and no renal treatment is provided.
What is the BEST CDI action?
Answer: C
Explanation:
A clinical validation query is appropriate because the documented diagnosis appears inconsistent with the available clinical evidence. The creatinine values remain essentially unchanged, urine output is normal, and there is no apparent treatment or monitoring consistent with acute renal dysfunction.
The CDI specialist cannot simply delete the diagnosis because providers are responsible for establishing diagnoses. Conversely, a diagnosis should not automatically be accepted when substantial clinical evidence raises a legitimate question about its validity.
A compliant query would present the documented AKI together with the pertinent renal findings and request clarification. The provider could confirm AKI and provide supporting clinical reasoning, revise the diagnosis, state that it was ruled out, or document another condition.
Assigning chronic kidney disease would be equally inappropriate because CKD requires evidence of chronic kidney abnormality and cannot be inferred from these laboratory values.
The August 2026 ACDIS/AHIMA query guidance supersedes prior versions and remains the foundational standard for clinical validation and documentation clarification.
Clinical validation protects data integrity because diagnoses influence reimbursement, quality reporting, severity measurement, utilization analysis, and downstream patient information.
CCDS Reference Topics: Clinical validation; AKI; unsupported diagnoses; provider clarification; compliance.
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NEW QUESTION # 100
A patient presents with fever, productive cough, and infiltrates in the right upper lobe per chest x-ray. The history and physical notes that the patient has pneumonia and hypotension. Cultures are drawn and the patient is admitted for IV antibiotics. On day 2, the patient's condition worsens, and the patient is transferred to the ICU for closer monitoring. The ICU physician documents sepsis. Which of the following statements is MOST accurate?
Answer: C
Explanation:
The key issue is whether the sepsis documented on hospital day 2 was present on admission (POA) or developed after admission. The admission already contains potentially relevant indicators-fever, pneumonia, hypotension, cultures, and IV antibiotic treatment-but a CDI specialist cannot independently determine from those indicators that sepsis was POA. Provider clarification is necessary.
This distinction directly affects principal-diagnosis sequencing. When sepsis and a localized infection such as pneumonia are both responsible for admission, the systemic infection is generally sequenced before the localized infection. Conversely, when the patient is admitted with pneumonia and sepsis develops only after admission, pneumonia is sequenced first.
The POA guidelines also emphasize that a diagnosis may not be recognized until days after admission and that delayed documentation does not automatically mean the condition was hospital-acquired. When timing is unclear, querying the provider is appropriate.
There is no evidence supporting aspiration pneumonia, so option B would introduce an unsupported concept.
Options C and D prematurely determine principal diagnosis without resolving the timing of sepsis.
CCDS Reference Topics: Sepsis sequencing; POA assignment; principal diagnosis; compliant clarification of timing.
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NEW QUESTION # 101
A patient's record contains fever, tachycardia, hypotension, positive blood cultures, and treatment with IV antibiotics and fluids. No corresponding diagnosis has been documented. Which query format is MOST appropriate?
Answer: C
Explanation:
A neutral multiple-choice query is appropriate when significant clinical indicators exist but no corresponding diagnosis has been documented. The query should present the relevant patient-specific facts and allow the provider to exercise independent clinical judgment among reasonable alternatives.
For example, depending on the complete record, options could include sepsis, localized infection without sepsis, bacteremia, another condition, or unable to determine. Each offered diagnosis must be clinically supported.
A yes/no query is generally inappropriate when it introduces a completely new diagnosis that has never appeared in the health record. Option B is overtly leading because it directs the provider to document sepsis rather than requesting clarification.
The 2026 ACDIS/AHIMA compliant-query guidance, published August 20, 2026, supersedes all previous versions and serves as the current foundational standard for CDI and coding query practice. It applies across inpatient, outpatient, ambulatory, and professional-fee settings.
The purpose of the query is documentation integrity-not obtaining an MCC, changing the MS-DRG, or achieving a particular quality result.
CCDS Reference Topics: Multiple-choice queries; missing diagnosis; nonleading queries; clinical indicators; compliance.
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NEW QUESTION # 102
A patient develops chest pain and elevated troponins while receiving care in the emergency department. The physician diagnoses an NSTEMI. Several hours later, an inpatient admission order is written. How should the NSTEMI generally be considered for POA purposes?
Answer: A
Explanation:
For POA reporting, "present on admission" refers to a condition present at the time the order for inpatient admission occurs. Conditions that develop during an outpatient encounter-including emergency-department, observation, or outpatient surgery care-before the inpatient admission order are generally considered POA when they are present at that inpatient admission point.
Therefore, the NSTEMI in this scenario is considered present on admission even though it developed after the patient physically arrived at the hospital.
This distinction is essential because hospital arrival and inpatient admission are not synonymous for POA purposes. A patient may spend hours in the ED or observation status before an inpatient order is entered.
The POA indicator applies to applicable principal and secondary diagnoses and is important to CMS's HAC payment provisions as well as quality analysis. A condition does not become hospital acquired merely because it arose somewhere on hospital premises before inpatient status began.
CDI specialists should clarify timing when the record does not establish whether a diagnosis existed before or after the inpatient admission order rather than relying solely on note timestamps or physical location.
The FY 2026 ICD-10-CM Official Guidelines contain the governing POA definitions and reporting rules.
CCDS Reference Topics: POA; emergency department; observation; timing of diagnosis; HAC payment logic.
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NEW QUESTION # 103
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