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| Section | Weight | Objectives |
|---|---|---|
| Impact of reportable diagnoses on quality of care | 8.33% | - Hospital Inpatient Quality Reporting Program - 30-day mortality measures - CDI impact on Hospital Value-Based Purchasing - Coded data elements affecting Patient Safety Indicators - Hospital Readmissions Reduction Program - Documentation and code assignment impact on mortality index - Hospital-Acquired Condition Reduction Program - Hospital Value-Based Purchasing - Patient Safety Indicators - Mortality reviews and observed/expected ratios - Healthcare-associated infections and complication codes - Quality data from record abstraction and claims data |
| Medical record documentation | 19.17% | - When a physician query is warranted - Provider role and diagnosis code assignment - ACDIS/AHIMA Guidelines for Achieving a Compliant Query Practice - Addressing diagnoses without clinical support - Types of physician queries - Compliant and noncompliant queries - Documentation requiring clarification - Translating clinical indicators into compliant queries - Health record elements used for diagnosis and procedure code assignment - Clinical indicators - Physician query formats - Situations in which queries are not appropriate |
| Official Guidelines for Coding and Reporting | 14.17% | - Secondary diagnosis assignment - AHA Coding Clinic - Official Guidelines for Coding and Reporting updates - Coding guidelines for principal diagnosis selection - Discharge dispositions and transfers - Working DRG assignment for multiple diagnoses - Present on admission indicators - Principal diagnosis assignment - Hospital-acquired conditions |
| 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 respiratory system - Diseases and disorders of the nervous system - Diagnostic tests as clinical indicators - Diseases and disorders of the musculoskeletal system - Diseases and disorders of the kidney and urinary tract - Diseases and disorders of the circulatory system - Infectious and parasitic diseases - Medications as clinical indicators - Clinical indicators and query opportunities by Major Diagnostic Category - Mental diseases and disorders - Diseases and disorders of the blood and blood-forming organs and immunological disorders - HIV infections - Diseases and disorders of the hepatobiliary system - Diseases and disorders of the digestive system - Pharmaceuticals and disease processes - Alcohol/drug use and alcohol/drug-induced organic brain disorders - Diseases and disorders of the skin, subcutaneous tissue, and breast - Endocrine, nutritional, and metabolic diseases and disorders - Myeloproliferative diseases and disorders and poorly differentiated neoplasms |
| Professionalism, ethics, and compliance | 9.17% | - Compliance risks indicated by PEPPER - CDI department goals beyond reimbursement - Potential DRG creep - DRG compliance initiatives - Leading queries - Medical record confidentiality |
| Healthcare regulations, reimbursement, and documentation requirements related to the IPPS | 12.5% | - Complication/comorbidity (CC) - Documentation impact on IPPS reimbursement - Documentation and medical necessity of setting - Principal diagnosis and medical necessity - Coding and billing practices vulnerable to denial - Inpatient admission criteria and CMS Two-Midnight Rule - IPPS and its updates and revisions - Case mix index (CMI) - Medicare Severity Diagnosis Related Groups (MS-DRGs) - Medicare contractors and their impact on CDI - Major complication/comorbidity (MCC) - Medical staff and clinical staff documentation responsibilities |
| Healthcare facility CDI program analysis | 8.33% | - Publicly reported data - Patient Safety Indicators - Basic computer and software application skills - CDI specialist productivity metrics - Hospital-specific financial data - CC/MCC capture - Physician performance measurement - Case mix index (CMI) - PEPPER data - Provider response rates - Severity of illness and risk of mortality - Tracking and trending physician, department, and hospital performance - High-frequency DRGs - CDI program forecasting - Hospital Value-Based Purchasing measures |
| Communication skills | 9.17% | - Effective and non-confrontational physician communication - Roles and responsibilities of CDI specialists - Roles and responsibilities of coders working with CDI departments - Physician education forms and tools - Educational presentations for healthcare departments and administration - Verbal versus written physician communication - Reconciling CDI working DRGs with final coded DRGs |
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NEW QUESTION # 101
Documentation indicates an excisional debridement was performed without further specification. The CDI specialist should query to clarify which of the following?
Answer: C
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 # 102
A patient's chest x-ray shows pulmonary vascular congestion and pleural effusions. These findings are most consistent with which of the following conditions?
Answer: C
Explanation:
Pulmonary vascular congestion accompanied by pleural effusions is classically associated with congestive heart failure, particularly left-sided or biventricular decompensation. Increased left-sided cardiac filling pressure raises pulmonary venous and capillary hydrostatic pressure, promoting interstitial and alveolar fluid accumulation. Fluid may also migrate into the pleural space, producing unilateral or bilateral pleural effusions.
Additional radiographic indicators of heart failure may include cardiomegaly, cephalization of pulmonary vessels, interstitial edema, Kerley B lines, perihilar alveolar opacities, and bilateral effusions. These findings should always be interpreted alongside symptoms and other clinical evidence such as dyspnea, orthopnea, edema, BNP/NT-proBNP, echocardiography, and response to diuretics.
COPD more commonly demonstrates hyperinflation, flattened diaphragms, and increased lucency rather than pulmonary vascular congestion. Cor pulmonale refers to right-sided cardiac dysfunction resulting from pulmonary disease and does not typically produce the classic pulmonary venous congestion pattern.
Pulmonary embolism may have a normal chest radiograph or nonspecific abnormalities, but pulmonary vascular congestion with effusions is not its characteristic pattern.
For CDI purposes, imaging provides a clinical indicator but does not independently establish the diagnosis or acuity of heart failure.
CCDS Reference Topics: Heart failure pathophysiology; chest radiography; clinical indicators; cardiopulmonary terminology.
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NEW QUESTION # 103
Hospital A is developing a query policy. Open-ended queries will be encouraged. The provider is expected to document on the query form, which will be retained as part of the health record. Hospital A will remove any unanswered queries and shred them to avoid any incomplete forms within the health record. Which of the following is considered a high-risk query practice?
Answer: C
Explanation:
The high-risk practice is destroying unanswered queries. Query retention should be governed by an established organizational policy and should not depend on whether the provider answers the query.
Selectively destroying unanswered queries can create significant compliance, audit, and record-integrity concerns because it removes evidence of the documentation-clarification process.
ACDIS/AHIMA guidance has consistently required organizations to establish query-retention policies.
Queries may be retained as part of the permanent health record or maintained as a retrievable business record according to organizational policy and legal requirements. The current 2026 ACDIS/AHIMA query practice guidance supersedes all previous editions, reinforcing the importance of a standardized, defensible query process.
Keeping queries in the health record is not inherently problematic when policy defines them as part of that record. Likewise, a new diagnosis may be included in a multiple-choice query when it is supported by patient- specific clinical indicators and the choices remain nonleading. A yes/no query can also be compliant in defined circumstances, such as clarification of a diagnosis or relationship already documented.
Selective destruction is therefore the clear compliance risk.
CCDS Reference Topics: Query retention; compliance; organizational query policy; audit integrity.
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NEW QUESTION # 104
A patient is admitted with fever, productive cough, and hypotension. The attending physician documents sepsis due to pneumonia. Acute kidney injury develops and is documented as due to sepsis. Which of the following is the MOST appropriate sequencing concept?
Answer: D
NEW QUESTION # 105
A CDI team identifies that orthopedic surgeons frequently document "postoperative anemia" without specifying whether blood loss is acute, expected, chronic, or clinically insignificant. What is the BEST educational strategy?
Answer: B
Explanation:
The strongest educational approach is targeted specialty-specific education using the surgeons' own documentation trends and realistic clinical examples. This addresses the recurring documentation problem while remaining clinically relevant to the audience.
Orthopedic surgeons do not need to become coding specialists. Education should instead explain which clinical distinctions matter-for example, whether anemia represents expected postoperative change, acute blood loss anemia, chronic anemia, or another diagnosis-and why accurate terminology improves the medical record.
Providing a long code list is unlikely to improve physician documentation behavior. Instructing surgeons to document acute blood loss anemia whenever hemoglobin decreases would be clinically inappropriate and could produce unsupported diagnoses. A postoperative hemoglobin decline may reflect hemodilution, expected surgical blood loss, chronic anemia, or other factors.
Stopping queries would leave meaningful ambiguities unresolved.
ACDIS/AHIMA query guidance emphasizes documentation accuracy and provider independence rather than reimbursement-focused diagnosis selection.
Successful physician education should be concise, clinically oriented, supported by service-line data, and reinforced when subsequent query trends demonstrate persistent problems.
CCDS Reference Topics: Physician education; communication; postoperative anemia; query trends; provider engagement.
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NEW QUESTION # 106
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