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| Section | Weight | Objectives |
|---|---|---|
| Topic 1: Communication skills | 9.17% | - Educational presentations for healthcare departments and administration - Verbal versus written physician communication - Roles and responsibilities of CDI specialists - 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 |
| Topic 2: Impact of reportable diagnoses on quality of care | 8.33% | - Patient Safety Indicators - Healthcare-associated infections and complication codes - Coded data elements affecting Patient Safety Indicators - Hospital-Acquired Condition Reduction Program - CDI impact on Hospital Value-Based Purchasing - Hospital Inpatient Quality Reporting Program - 30-day mortality measures - Mortality reviews and observed/expected ratios - Quality data from record abstraction and claims data - Hospital Value-Based Purchasing - Documentation and code assignment impact on mortality index - Hospital Readmissions Reduction Program |
| Topic 3: Anatomy and physiology, pathophysiology, pharmacology, and medical terminology | 19.17% | - Mental diseases and disorders - HIV infections - Alcohol/drug use and alcohol/drug-induced organic brain disorders - Standard medical abbreviations - Medications as clinical indicators - Diseases and disorders of the skin, subcutaneous tissue, and breast - Diseases and disorders of the nervous system - Diseases and disorders of the kidney and urinary tract - Diagnostic tests as clinical indicators - Diseases and disorders of the respiratory system - Diseases and disorders of the digestive system - Pharmaceuticals and disease processes - Diseases and disorders of the circulatory system - Infectious and parasitic diseases - Diseases and disorders of the hepatobiliary system - Endocrine, nutritional, and metabolic diseases and disorders - Injuries, poisonings, and toxic effects of drugs - Clinical indicators and query opportunities by Major Diagnostic Category - Diseases and disorders of the musculoskeletal system - Myeloproliferative diseases and disorders and poorly differentiated neoplasms - Diseases and disorders of the blood and blood-forming organs and immunological disorders |
| Topic 4: Professionalism, ethics, and compliance | 9.17% | - Compliance risks indicated by PEPPER - Medical record confidentiality - DRG compliance initiatives - CDI department goals beyond reimbursement - Leading queries - Potential DRG creep |
| Topic 5: Healthcare regulations, reimbursement, and documentation requirements related to the IPPS | 12.5% | - Medicare contractors and their impact on CDI - Major complication/comorbidity (MCC) - Coding and billing practices vulnerable to denial - Medical staff and clinical staff documentation responsibilities - Complication/comorbidity (CC) - Principal diagnosis and medical necessity - Documentation impact on IPPS reimbursement - IPPS and its updates and revisions - Case mix index (CMI) - Inpatient admission criteria and CMS Two-Midnight Rule - Documentation and medical necessity of setting - Medicare Severity Diagnosis Related Groups (MS-DRGs) |
| Topic 6: Medical record documentation | 19.17% | - ACDIS/AHIMA Guidelines for Achieving a Compliant Query Practice - Health record elements used for diagnosis and procedure code assignment - Addressing diagnoses without clinical support - Types of physician queries - Provider role and diagnosis code assignment - Situations in which queries are not appropriate - Physician query formats - Documentation requiring clarification - Compliant and noncompliant queries - When a physician query is warranted - Clinical indicators - Translating clinical indicators into compliant queries |
| Topic 7: Official Guidelines for Coding and Reporting | 14.17% | - Working DRG assignment for multiple diagnoses - Present on admission indicators - Coding guidelines for principal diagnosis selection - Official Guidelines for Coding and Reporting updates - Hospital-acquired conditions - Secondary diagnosis assignment - AHA Coding Clinic - Discharge dispositions and transfers - Principal diagnosis assignment |
| Topic 8: Healthcare facility CDI program analysis | 8.33% | - High-frequency DRGs - Patient Safety Indicators - Hospital Value-Based Purchasing measures - Physician performance measurement - Publicly reported data - CDI program forecasting - PEPPER data - Hospital-specific financial data - Provider response rates - Severity of illness and risk of mortality - Basic computer and software application skills - Case mix index (CMI) - CDI specialist productivity metrics - Tracking and trending physician, department, and hospital performance - CC/MCC capture |
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NEW QUESTION # 103
At discharge, the physician documents, "Possible gram-negative pneumonia." No later documentation rules out the condition. How should the diagnosis generally be handled for an inpatient admission?
Answer: C
Explanation:
In the inpatient hospital setting, an uncertain diagnosis documented at discharge using terminology such as possible, probable, suspected, likely, questionable, compatible with, or consistent with may generally be coded as though the condition existed or was established.
Therefore, "possible gram-negative pneumonia" may be coded in accordance with the inpatient uncertain- diagnosis guideline when it remains the final diagnostic conclusion.
The rationale is that inpatient diagnostic evaluation and treatment frequently occur before absolute confirmation is available, and the patient may have been managed as though the suspected disease were present.
This rule is materially different from outpatient coding, where uncertain diagnoses are generally not coded as established and the documented signs, symptoms, or confirmed conditions are reported instead.
The presence of the uncertain terminology alone does not mandate a query. A query would be appropriate if documentation is contradictory, if the diagnosis is clinically unsupported, or if another documentation issue prevents correct code assignment.
CDI specialists need to recognize this inpatient-specific rule because unnecessary queries for "possible" or
"probable" diagnoses can create physician burden without improving coding accuracy.
CCDS Reference Topics: Uncertain inpatient diagnoses; discharge documentation; pneumonia; inpatient versus outpatient coding.
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NEW QUESTION # 104
A registered dietitian documents severe malnutrition based on substantial weight loss, severe muscle depletion, and prolonged inadequate energy intake. The attending physician documents only "poor oral intake." What is the BEST action for the CDI specialist?
Answer: A
Explanation:
The appropriate action is to query the provider regarding the patient's nutritional diagnosis. The dietitian's assessment supplies important clinical evidence, but the associated diagnosis of malnutrition generally must be documented by an appropriate provider before the diagnosis code is assigned.
The FY 2026 ICD-10-CM Official Guidelines permit selected elements to come from non-provider clinicians-such as BMI, pressure-ulcer stage, coma scale, NIH Stroke Scale, certain social determinants, and other specifically identified exceptions. Malnutrition diagnosis itself is not simply assigned solely from a dietitian's diagnostic statement under this general rule.
Ignoring the dietitian's findings would also be inappropriate. CDI review should integrate multidisciplinary documentation because such documentation can reveal valid clarification opportunities. Severe weight loss, reduced intake, and documented muscle depletion provide a clinical basis for a neutral query.
The query should not state that severe malnutrition "must" be documented because it is an MCC. Instead, it should present the relevant nutrition findings and allow the provider to determine the diagnosis, including severe malnutrition, another level of malnutrition, another cause, or inability to determine.
CCDS Reference Topics: Malnutrition; multidisciplinary documentation; provider diagnosis requirements; clinical indicators.
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NEW QUESTION # 105
Based on the AHIMA/ACDIS Practice Brief Guidelines for Achieving a Compliant Query Practice, a leading query is one that:
Answer: D
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 # 106
A CDI director wants to evaluate whether physicians are consistently addressing clarification requests. Which metric most directly measures this aspect of physician engagement?
Answer: B
Explanation:
The provider query response rate most directly measures whether physicians are responding to CDI clarification requests. It evaluates participation in the query process regardless of whether the provider agrees with the diagnosis suggested by the clinical circumstances.
This distinction is important. A high agreement rate is not necessarily the goal of a compliant CDI program.
Providers should be free to disagree, document an alternative condition, state that a diagnosis was ruled out, or indicate that the issue cannot be determined. A very high response rate combined with clinically independent responses represents stronger engagement than an artificial focus on agreement.
Case mix index measures the average relative resource intensity of the hospital's MS-DRGs and is influenced by numerous clinical, coding, surgical, and case-mix factors. CC capture reflects diagnosis severity patterns but does not directly demonstrate physician responsiveness. CDI review rate is primarily a departmental workflow/productivity measure.
The official CCDS content outline specifically lists provider response rates, CMI, CDI productivity metrics, physician-performance measurement, and longitudinal trending among CDI program-analysis competencies.
A mature program should analyze response rate by service line, provider, query type, response time, and escalation frequency.
CCDS Reference Topics: Provider response rate; physician engagement; CDI analytics; query metrics; program performance.
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NEW QUESTION # 107
A patient with colon cancer is admitted solely for transfusion and management of anemia caused directly by the malignancy. No chemotherapy-related adverse effect is involved. Which condition is sequenced first?
Answer: D
Explanation:
When the admission is for management of anemia associated directly with the malignancy, and treatment is directed only at the anemia, the malignancy is sequenced as principal diagnosis, followed by the appropriate anemia code.
The FY 2026 Official Guidelines specifically distinguish malignancy-associated anemia from anemia caused by chemotherapy. For anemia associated with the malignancy, the neoplasm is sequenced first. For anemia resulting from an adverse effect of chemotherapy or immunotherapy, the anemia code is sequenced first.
This distinction makes documentation of anemia etiology essential. Phrases such as "anemia in cancer patient" may not clearly establish whether anemia is attributable to malignancy, chemotherapy, bleeding, nutritional deficiency, chronic kidney disease, or another process.
An encounter code for transfusion does not replace the principal-diagnosis rules for an inpatient hospitalization when the underlying reason for treatment is established.
Likewise, weakness is a symptom and would not supersede the definitive documented cancer-related anemia.
CDI professionals should therefore look beyond the fact that transfusion occurred and identify whether the medical record clearly establishes the cause of the anemia.
CCDS Reference Topics: Neoplasm-related anemia; principal diagnosis; sequencing; chemotherapy versus malignancy; medical record specificity.
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NEW QUESTION # 108
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