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108. Frage
The progress note on hospital day 2 of a patient's admission states that the patient got up from the bed to go to the bathroom just after housekeeping had mopped the floor. The patient slipped and fell onto the floor, sustaining a broken wrist. The diagnosis of a fractured wrist will:
Antwort: C
Begründung:
The fracture occurred after inpatient admission as the result of a hospital fall, placing it within CMS's Hospital-Acquired Condition category for Falls and Trauma when the applicable fracture code is included in the HAC code list. CMS's FY 2026 MS-DRG Definitions Manual continues to identify qualifying fracture codes within HAC 05.
The fracture must still be coded; therefore, option D is incorrect. Because it clearly developed after admission, it would not appropriately receive POA indicator "U," which indicates insufficient documentation to determine whether the condition was present on admission.
For qualifying HAC diagnoses that are not POA, CMS payment logic prevents the hospital from receiving the higher MS-DRG payment that would otherwise result solely from the condition's CC/MCC status. Thus, option B expresses the intended payment effect.
This distinction is central to CDI practice: a hospital-acquired diagnosis does not disappear from the record or coding. It remains reportable for clinical and quality purposes, but certain qualifying HACs are treated differently in MS-DRG payment calculations.
CCDS Reference Topics: HACs; POA indicators; Falls and Trauma; MS-DRG payment adjustment.
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109. Frage
A patient accidentally takes twice the prescribed dose of warfarin and develops gastrointestinal bleeding.
Which coding concept applies?
Antwort: D
Begründung:
Taking more medication than prescribed constitutes poisoning under ICD-10-CM drug-event rules. The drug may have been correctly prescribed, but the patient took an incorrect amount.
For poisoning, the applicable poisoning code is generally sequenced first, followed by codes identifying manifestations such as gastrointestinal bleeding.
This differs from an adverse effect, in which a drug is correctly prescribed and properly administered but causes an undesirable reaction. In adverse-effect scenarios, the nature of the adverse effect is coded first, followed by the drug code with the appropriate adverse-effect character.
Underdosing applies when the patient takes less of a medication than prescribed, whether intentionally or unintentionally. It does not describe excessive dosing.
For CDI specialists, determining whether an event represents poisoning, adverse effect, or underdosing requires careful review of how the medication was prescribed and actually taken. Phrases such as "warfarin- related bleeding" may not always provide enough information to determine the correct classification.
A clarification query may therefore be appropriate when dose, intent, or medication-use circumstances are unclear.
CCDS Reference Topics: Poisoning; adverse effects; underdosing; medication events; sequencing.
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110. Frage
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?
Antwort: D
Begründung:
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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111. Frage
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?
Antwort: A
Begründung:
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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112. Frage
A CDI manager finds that cardiology providers receive repeated queries for heart-failure acuity and type.
Which educational intervention is MOST appropriate?
Antwort: D
Begründung:
The most effective intervention is targeted, service-line-specific physician education based on actual documentation trends and clinically relevant examples.
Repeated queries for the same issue usually indicate a systematic documentation opportunity rather than isolated provider mistakes. Education should therefore show cardiologists how documentation of heart-failure type-such as systolic, diastolic, or combined-and acuity-acute, chronic, or acute on chronic- communicates the patient's clinical condition more precisely.
Using deidentified examples from the service line makes the education immediately relevant and enables physicians to recognize which clinical circumstances frequently generate clarification. Aggregate query data can demonstrate where documentation gaps occur without criticizing individual providers.
Sending an entire code book places coding responsibility on physicians and is unlikely to change documentation behavior. Stopping queries leaves unresolved clinical ambiguity. Framing the education around reduced reimbursement is also inappropriate because the goal of CDI education is accurate clinical representation, not coaching physicians toward higher-paying diagnoses.
The 2026 ACDIS/AHIMA query guidance identifies accurate representation of the patient's clinical status as the underlying purpose of CDI clarification.
CCDS Reference Topics: Physician education; communication; heart-failure specificity; query trend analysis.
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113. Frage
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