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| Section | Weight | Objectives |
|---|---|---|
| Topic 1: Official Guidelines for Coding and Reporting | 14.17% | - Secondary diagnosis assignment - Hospital-acquired conditions - Present on admission indicators - Principal diagnosis assignment - Coding guidelines for principal diagnosis selection - Discharge dispositions and transfers - Working DRG assignment for multiple diagnoses - Official Guidelines for Coding and Reporting updates - AHA Coding Clinic |
| Topic 2: Communication skills | 9.17% | - Roles and responsibilities of coders working with CDI departments - Roles and responsibilities of CDI specialists - Physician education forms and tools - Reconciling CDI working DRGs with final coded DRGs - Effective and non-confrontational physician communication - Verbal versus written physician communication - Educational presentations for healthcare departments and administration |
| Topic 3: Medical record documentation | 19.17% | - Translating clinical indicators into compliant queries - Clinical indicators - Addressing diagnoses without clinical support - When a physician query is warranted - Types of physician queries - ACDIS/AHIMA Guidelines for Achieving a Compliant Query Practice - Health record elements used for diagnosis and procedure code assignment - Compliant and noncompliant queries - Provider role and diagnosis code assignment - Situations in which queries are not appropriate - Physician query formats - Documentation requiring clarification |
| Topic 4: Anatomy and physiology, pathophysiology, pharmacology, and medical terminology | 19.17% | - Myeloproliferative diseases and disorders and poorly differentiated neoplasms - Infectious and parasitic diseases - HIV infections - Diseases and disorders of the circulatory system - Diseases and disorders of the respiratory system - Standard medical abbreviations - Diseases and disorders of the nervous system - Diseases and disorders of the hepatobiliary system - Endocrine, nutritional, and metabolic diseases and disorders - Alcohol/drug use and alcohol/drug-induced organic brain disorders - Pharmaceuticals and disease processes - Medications as clinical indicators - Diseases and disorders of the musculoskeletal system - Diseases and disorders of the skin, subcutaneous tissue, and breast - Diseases and disorders of the kidney and urinary tract - Diagnostic tests as clinical indicators - Diseases and disorders of the blood and blood-forming organs and immunological disorders - Injuries, poisonings, and toxic effects of drugs - Clinical indicators and query opportunities by Major Diagnostic Category - Mental diseases and disorders - Diseases and disorders of the digestive system |
| Topic 5: Impact of reportable diagnoses on quality of care | 8.33% | - Patient Safety Indicators - Hospital Readmissions Reduction Program - Healthcare-associated infections and complication codes - Mortality reviews and observed/expected ratios - Documentation and code assignment impact on mortality index - Coded data elements affecting Patient Safety Indicators - 30-day mortality measures - Hospital Value-Based Purchasing - Quality data from record abstraction and claims data - Hospital Inpatient Quality Reporting Program - CDI impact on Hospital Value-Based Purchasing - Hospital-Acquired Condition Reduction Program |
| Topic 6: Healthcare regulations, reimbursement, and documentation requirements related to the IPPS | 12.5% | - Major complication/comorbidity (MCC) - IPPS and its updates and revisions - Coding and billing practices vulnerable to denial - Complication/comorbidity (CC) - Medicare Severity Diagnosis Related Groups (MS-DRGs) - Documentation impact on IPPS reimbursement - Documentation and medical necessity of setting - Principal diagnosis and medical necessity - Case mix index (CMI) - Medical staff and clinical staff documentation responsibilities - Medicare contractors and their impact on CDI - Inpatient admission criteria and CMS Two-Midnight Rule |
| Topic 7: Professionalism, ethics, and compliance | 9.17% | - CDI department goals beyond reimbursement - Medical record confidentiality - Potential DRG creep - Leading queries - DRG compliance initiatives - Compliance risks indicated by PEPPER |
| Topic 8: Healthcare facility CDI program analysis | 8.33% | - Patient Safety Indicators - PEPPER data - Basic computer and software application skills - Physician performance measurement - Provider response rates - CDI program forecasting - CDI specialist productivity metrics - Hospital Value-Based Purchasing measures - Severity of illness and risk of mortality - Case mix index (CMI) - Publicly reported data - CC/MCC capture - High-frequency DRGs - Hospital-specific financial data - Tracking and trending physician, department, and hospital performance |
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NEW QUESTION # 149
A neurologist documents acute cerebral infarction. A qualified stroke nurse records the NIH Stroke Scale score in the medical record. Which statement is MOST accurate?
Answer: C
Explanation:
ICD-10-CM permits the NIH Stroke Scale score to be reported from documentation by an appropriate clinician other than the provider responsible for establishing the diagnosis. The underlying stroke diagnosis itself must be appropriately documented by the provider.
This is similar to other specified exceptions such as BMI, pressure-ulcer stage, coma scale values, and certain additional clinical elements for which qualified non-provider documentation may support code assignment.
The exception does not mean that a stroke nurse can independently establish cerebral infarction for coding.
Rather, once the provider has documented the stroke, the nurse's formal NIHSS assessment can supply the standardized severity measurement.
This approach recognizes that specially trained clinical professionals routinely collect and document these structured measurements as part of patient care.
If multiple NIHSS values are documented, the applicable coding instructions and timing requirements should be followed rather than simply selecting the highest score because it produces a different code.
For CDI professionals, awareness of these non-provider documentation exceptions prevents unnecessary physician queries while ensuring that important severity information is not lost.
CCDS Reference Topics: NIH Stroke Scale; cerebral infarction; non-provider documentation; coding exceptions; stroke severity.
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NEW QUESTION # 150
A patient experienced a type 1 STEMI 10 days ago. The patient is readmitted and develops a new type 1 NSTEMI during the four-week acute myocardial infarction period. Which ICD-10-CM concept applies?
Answer: B
Explanation:
ICD-10-CM provides category I22 for a subsequent acute myocardial infarction occurring within four weeks-28 days-of an initial acute MI, when the qualifying MI types and circumstances meet the classification requirements.
The FY 2026 Official Guidelines specify that when a patient with a type 1 or unspecified acute MI experiences a new type 1 or unspecified MI within four weeks of the initial MI, a code from category I22 is used together with the appropriate I21 code. Sequencing depends on the circumstances of the encounter.
This rule requires care because type 2 MI and certain other myocardial infarction classifications do not follow the same I22 subsequent-MI logic. CDI specialists therefore need accurate documentation of MI type, anatomic location when applicable, timing, and whether the current event represents a genuinely new infarction rather than ongoing care for the original MI.
The prior STEMI does not become an "old MI" merely because the patient left the hospital; the ICD-10-CM acute MI period extends for four weeks from onset.
CCDS Reference Topics: Acute MI; subsequent MI; I21/I22; four-week rule; cardiovascular coding.
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NEW QUESTION # 151
When reviewing a patient's chart in the ICU, a CDI specialist determines a query needs to be placed. As the query is being written, the attending physician is leaving the patient's room after completing rounds. Which of the following is the BEST action to take?
Answer: A
Explanation:
A verbal query is the most efficient and appropriate action because the responsible physician is immediately available and the documentation gap has already been identified. CDI practice is not limited to written or electronic queries; verbal clarification is an accepted communication method when conducted compliantly.
The CDI specialist should present the relevant clinical indicators objectively and ask for clarification without directing the physician toward a preferred diagnosis. The conversation should remain clinically focused and must not mention reimbursement, MS-DRG impact, quality scoring, or other incentives.
Importantly, verbal does not mean informal or undocumented. Current query standards require organizations to maintain an auditable query process. Historically, ACDIS/AHIMA guidance has specifically required the essence of verbal queries to be memorialized, including the reason for clarification and relevant clinical indicators. The 2026 ACDIS/AHIMA Guidelines for Achieving a Compliant Query Practice supersede previous versions and remain the current foundational industry standard for query practice.
Waiting unnecessarily could delay clarification and interfere with concurrent CDI workflow. Since the physician is available, direct professional communication is preferable.
CCDS Reference Topics: Communication skills; verbal queries; concurrent CDI review; compliant query practice.
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NEW QUESTION # 152
A patient without chronic hypercapnia develops severe respiratory distress. ABG results are pH 7.19, PaCO#
74 mmHg, and PaO# 60 mmHg. The patient requires emergent BiPAP. Which condition is MOST strongly supported for clarification?
Answer: B
Explanation:
The findings strongly support clarification of acute hypercapnic respiratory failure. PaCO# of 74 mmHg represents marked carbon dioxide retention, while pH 7.19 demonstrates significant respiratory acidemia. The patient is also hypoxemic and requires urgent noninvasive ventilatory assistance.
Because there is no documented chronic hypercapnic baseline, the available information primarily supports an acute process rather than chronic respiratory failure.
Acute hypercapnia occurs when alveolar ventilation becomes insufficient to eliminate carbon dioxide.
Potential causes include COPD or asthma exacerbation, central nervous system depression, neuromuscular weakness, obesity hypoventilation, airway obstruction, or severe fatigue.
BiPAP provides positive-pressure ventilatory support and can improve alveolar ventilation, decrease work of breathing, and lower PaCO#.
The CDI specialist should not independently establish respiratory failure solely from an ABG. However, the combination of severe physiologic abnormality, respiratory distress, and escalation to BiPAP supplies a strong basis for provider clarification when no corresponding diagnosis is documented.
Metabolic alkalosis would ordinarily involve primary bicarbonate elevation with alkalemia rather than profound respiratory acidemia.
CCDS Reference Topics: Acute respiratory failure; hypercapnia; ABG interpretation; noninvasive ventilation; clinical indicators.
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NEW QUESTION # 153
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 # 154
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