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| Section | Weight | Objectives |
|---|---|---|
| Topic 1: Healthcare facility CDI program analysis | 8.33% | - CDI productivity, provider response, CMI, and program metrics - Data analysis, forecasting, and performance measurement |
| Topic 2: Official Guidelines for Coding and Reporting | 14.17% | - Principal and secondary diagnosis assignment - Coding guidelines, AHA Coding Clinic, HACs, and POA indicators |
| Topic 3: Professionalism, ethics, and compliance | 9.17% | - Query compliance, DRG creep, and audit risks - Confidentiality, DRG compliance, and ethical CDI practices |
| Topic 4: Anatomy and physiology, pathophysiology, pharmacology, and medical terminology | 19.17% | - Clinical conditions and clinical indicators - Anatomy, physiology, pathophysiology, pharmacology, and terminology |
| Topic 5: 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 |
| Topic 6: Medical record documentation | 19.17% | - Documentation clarification and compliant physician queries - Documentation requirements and diagnosis or procedure code assignment |
| Topic 7: 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 |
| Topic 8: Communication skills | 9.17% | - CDI and coding roles and interdisciplinary collaboration - Physician education and effective communication |
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NEW QUESTION # 73
The attending physician documents "severe protein-calorie malnutrition." The dietitian's assessment documents normal nutritional intake, stable body weight, no fat loss, and no muscle wasting. What should the CDI specialist do?
Answer: A
Explanation:
This is an appropriate clinical validation query because the provider has documented a diagnosis while the available clinical information appears inconsistent with that diagnosis.
The CDI specialist should not automatically accept every documented diagnosis when substantial contradictory clinical evidence exists. Conversely, CDI cannot independently delete the physician's diagnosis or replace the physician's clinical judgment.
The query should objectively identify the documented severe malnutrition and relevant contradictory findings-for example, stable weight, adequate nutritional intake, and absence of documented muscle or fat loss-and ask the provider to clarify whether severe malnutrition remains clinically appropriate, whether another nutritional condition better describes the patient, whether the diagnosis has been ruled out, or whether additional clinical reasoning supports it.
The query must remain neutral and should not mention the MCC status or potential reimbursement effect of severe malnutrition.
The August 2026 ACDIS/AHIMA compliant-query guidance supersedes previous editions and is the current foundational standard for compliant documentation clarification.
CCDS Reference Topics: Clinical validation; malnutrition; conflicting clinical indicators; compliant queries; documentation integrity.
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NEW QUESTION # 74
A patient is admitted with pneumonia. On hospital day 3, the patient deteriorates and the physician documents that sepsis developed after admission as a consequence of the pneumonia. Which diagnosis is generally sequenced first?
Answer: D
Explanation:
When a patient is admitted with a localized infection and sepsis develops after admission, the localized infection is generally sequenced as the principal diagnosis, followed by the appropriate sepsis code.
The FY 2026 ICD-10-CM Official Guidelines explicitly distinguish this circumstance from cases in which both the localized infection and sepsis are present on admission. When sepsis develops only after admission, the localized infection responsible for the original hospitalization remains principal.
Therefore, pneumonia is sequenced first in this scenario.
If the patient subsequently develops acute organ dysfunction related to sepsis and the provider documents severe sepsis, additional severe-sepsis and organ-dysfunction codes are assigned as appropriate. The severe- sepsis code cannot itself serve as principal diagnosis.
This question demonstrates why CDI specialists must clarify timing. Simply seeing both "pneumonia" and
"sepsis" in a discharge summary is insufficient to determine correct sequencing when the onset relationship is unclear.
The POA status of sepsis also becomes relevant because documentation indicates that it developed after inpatient admission.
CCDS Reference Topics: Sepsis; pneumonia; sequencing; timing; POA; principal diagnosis.
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NEW QUESTION # 75
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: B
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 # 76
A physician documents obesity. A registered dietitian records a BMI of 38.4 kg/m². Which statement is MOST accurate?
Answer: C
Explanation:
BMI is one of the recognized ICD-10-CM non-provider documentation exceptions. A qualified clinician such as a registered dietitian may document the BMI value, while the associated diagnosis-such as overweight or obesity-must be appropriately documented by the responsible provider.
Therefore, the coder may use the documented BMI of 38.4 in conjunction with the provider's obesity diagnosis when reporting requirements are otherwise satisfied.
The BMI itself does not permit the coder or CDI specialist to independently diagnose obesity or determine obesity type. Clinical diagnosis remains the provider's responsibility.
This distinction prevents unnecessary physician queries merely to reproduce objective measurements that have already been reliably documented by another qualified clinician.
Comparable non-provider documentation exceptions include pressure-ulcer stage and certain standardized scales or clinical details under applicable ICD-10-CM guidance.
CDI specialists should know these exceptions because unnecessary queries increase provider burden and can delay coding without improving data quality. Conversely, they should not extend the exception beyond what ICD-10-CM permits.
CCDS Reference Topics: BMI; obesity; non-provider documentation; dietitian documentation; coding exceptions.
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NEW QUESTION # 77
A patient has a history of a type 2 MI 30 days ago. The patient is admitted for chest pain which is determined to be an NSTEMI. Which of the following diagnosis(es) should be coded to identify the working MS-DRG?
Answer: A
Explanation:
The current NSTEMI is the acute condition driving the admission. The prior type 2 myocardial infarction occurred 30 days earlier, placing it beyond the ICD-10-CM four-week acute-MI reporting window. The Official Guidelines state that category I21 codes may continue to be reported while an MI is four weeks old or less; after that period, an aftercare code may be appropriate when continued MI-related care is being provided, or I25.2 may describe an old/healed MI when applicable.
There is an additional reason not to select a "subsequent MI" answer. Category I22 is restricted to qualifying subsequent type 1 or unspecified acute myocardial infarctions occurring within four weeks of the initial qualifying MI. Type 2 MI is classified to I21.A1 rather than I22.
Therefore, the previous type 2 MI does not support selection of a subsequent-MI option in this 30-day scenario. The active NSTEMI is the diagnosis relevant to the working MS-DRG. "Initial encounter" in answer B is exam terminology rather than an ICD-10-CM seventh-character designation for MI, but B is clearly the intended correct choice.
CCDS Reference Topics: Official Guidelines-acute myocardial infarction; working MS-DRG; circulatory disorders.
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NEW QUESTION # 78
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