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| Section | Weight | Objectives |
|---|---|---|
| Impact of reportable diagnoses on quality of care | 8.33% | - Mortality, severity of illness, and risk of mortality - Quality metrics, reporting programs, and financial impact |
| Communication skills | 9.17% | - Physician education and effective communication - CDI and coding roles and interdisciplinary collaboration |
| Healthcare facility CDI program analysis | 8.33% | - Data analysis, forecasting, and performance measurement - CDI productivity, provider response, CMI, and program metrics |
| Healthcare regulations, reimbursement, and documentation requirements related to the IPPS | 12.5% | - IPPS, MS-DRGs, reimbursement, and medical necessity - CC/MCC, CMI, Medicare contractors, and compliance |
| Official Guidelines for Coding and Reporting | 14.17% | - Coding guidelines, AHA Coding Clinic, HACs, and POA indicators - Principal and secondary diagnosis assignment |
| Professionalism, ethics, and compliance | 9.17% | - Query compliance, DRG creep, and audit risks - Confidentiality, DRG compliance, and ethical CDI practices |
| Anatomy and physiology, pathophysiology, pharmacology, and medical terminology | 19.17% | - Clinical conditions and clinical indicators - Anatomy, physiology, pathophysiology, pharmacology, and terminology |
| Medical record documentation | 19.17% | - Documentation clarification and compliant physician queries - Documentation requirements and diagnosis or procedure code assignment |
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NEW QUESTION # 108
A hospital has 2,500 inpatient discharges and a cumulative MS-DRG relative weight of 4,375. What is the hospital's case mix index?
Answer: B
Explanation:
Case mix index is calculated as:
Total MS-DRG relative weights ÷ Total inpatient discharges
Therefore:
4,375 ÷ 2,500 = 1.75
The hospital's CMI is 1.75.
CMI provides an aggregate indication of the average relative resource intensity of the hospital's inpatient population. Because each MS-DRG carries a relative weight, hospitals treating larger numbers of complex medical or surgical cases typically have higher CMIs than hospitals treating less resource-intensive populations.
CMI is not a direct quality score and should not be interpreted as a pure measure of CDI performance. It can change because of service-line mix, surgical volume, patient acuity, transfers, annual MS-DRG recalibration, coding accuracy, documentation quality, and other operational changes.
CMS maintains the FY 2026 MS-DRG Definitions Manual and grouper logic, currently Version 43.1 for April 1 through September 30, 2026.
A CDI manager should therefore analyze unexpected CMI changes alongside service-line trends, query activity, coding reconciliation, procedure volumes, and diagnosis patterns.
CCDS Reference Topics: CMI; relative weights; CDI analytics; MS-DRGs; trend analysis.
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NEW QUESTION # 109
Based on the AHIMA/ACDIS Practice Brief Guidelines for Achieving a Compliant Query Practice, a leading query is one that:
Answer: A
Explanation:
A query becomes problematic when it directs or influences the provider toward a diagnosis that is not supported by the patient's clinical record. Therefore, option C most accurately represents the leading-query concept in this answer set. A compliant query must be based on patient-specific clinical indicators and must preserve the provider's independent clinical judgment.
A multiple-choice query may include a diagnosis not previously documented when that diagnosis is supported by the clinical indicators and when reasonable alternatives are also offered. ACDIS/AHIMA guidance has specifically recognized that presenting a clinically supported new diagnosis among neutral choices does not automatically make the query leading.
Likewise, the timing of a query while a provider is documenting does not make it leading. Cause-and-effect clarification may also be addressed using an appropriate query format when both conditions are documented and the relationship remains uncertain.
The current 2026 ACDIS/AHIMA Guidelines for Achieving a Compliant Query Practice supersede the prior versions and continue to establish compliant provider-query practice as a foundational CDI standard. Queries must be clinically supported, noncoercive, and constructed without reference to reimbursement or other desired outcomes.
CCDS Reference Topics: Leading queries; clinical indicators; compliant query construction; provider independence.
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NEW QUESTION # 110
The documentation is insufficient to determine whether a reportable diagnosis was present at the time of inpatient admission. Which POA indicator represents this situation?
Answer: D
Explanation:
POA indicator U means that the documentation is insufficient to determine whether the condition was present on admission.
This is different from Y, which indicates that the condition was present when inpatient admission occurred, and N, which indicates that the condition was not present at admission. Indicator W is used when the provider is unable to clinically determine whether the condition was present at the time of inpatient admission.
The distinction between U and W is especially important. U reflects inadequacy of the documentation, whereas W reflects a clinical determination that the timing cannot be established despite appropriate evaluation.
CDI specialists should generally attempt to resolve unclear timing when clinically feasible before a case reaches final coding. Accurate POA assignment can influence CMS Hospital-Acquired Condition payment logic and quality measurement.
CMS publishes an annual list of diagnoses exempt from POA reporting and maintains the FY 2026 POA resources separately from the HAC code lists.
POA reporting focuses on the condition's status at inpatient admission, not merely when it was first documented or when diagnostic confirmation became available.
CCDS Reference Topics: POA indicators; U versus W; HACs; admission timing; inpatient reporting.
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NEW QUESTION # 111
A CDI program is developing a query escalation policy. A clinically significant query remains unanswered despite normal reminders. Which action is MOST appropriate?
Answer: D
Explanation:
An unanswered clinically significant query should be managed through the organization's defined escalation process. The process may involve CDI leadership, coding leadership, a physician advisor, department leadership, or other designated personnel, depending on organizational policy.
Neither CDI nor coding may independently supply the missing diagnosis because diagnostic conclusions remain the provider's responsibility. Removing an unresolved query simply to accelerate billing can undermine documentation integrity and may create compliance problems.
Escalation policies should be standardized rather than applied only when a particular diagnosis affects reimbursement. Policies commonly address expected response time, reminder intervals, responsible escalation personnel, high-priority queries, retrospective queries, and final-bill procedures.
The 2026 ACDIS/AHIMA Guidelines for Achieving a Compliant Query Practice supersede prior versions and serve as the current foundational guidance for organizations establishing compliant query policies and procedures.
A mature escalation process balances timely claim completion with respect for provider workload and independent clinical judgment. Its purpose is obtaining complete and accurate documentation, not forcing agreement with a CDI-generated diagnosis.
CCDS Reference Topics: Query escalation; organizational policy; unanswered queries; compliance; provider responsibility.
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NEW QUESTION # 112
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: A
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 # 113
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