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| Section | Weight | Objectives |
|---|---|---|
| Medical record documentation | 19.17% | - Clinical indicators - When a physician query is warranted - Physician query formats - Health record elements used for diagnosis and procedure code assignment - Translating clinical indicators into compliant queries - Provider role and diagnosis code assignment - Documentation requiring clarification - Situations in which queries are not appropriate - Compliant and noncompliant queries - Addressing diagnoses without clinical support - ACDIS/AHIMA Guidelines for Achieving a Compliant Query Practice - Types of physician queries |
| Professionalism, ethics, and compliance | 9.17% | - Medical record confidentiality - DRG compliance initiatives - Potential DRG creep - CDI department goals beyond reimbursement - Compliance risks indicated by PEPPER - Leading queries |
| Official Guidelines for Coding and Reporting | 14.17% | - Hospital-acquired conditions - Coding guidelines for principal diagnosis selection - Discharge dispositions and transfers - Present on admission indicators - Principal diagnosis assignment - AHA Coding Clinic - Official Guidelines for Coding and Reporting updates - Secondary diagnosis assignment - Working DRG assignment for multiple diagnoses |
| Impact of reportable diagnoses on quality of care | 8.33% | - Patient Safety Indicators - Hospital Value-Based Purchasing - Hospital Inpatient Quality Reporting Program - Mortality reviews and observed/expected ratios - Documentation and code assignment impact on mortality index - Quality data from record abstraction and claims data - Hospital-Acquired Condition Reduction Program - Hospital Readmissions Reduction Program - 30-day mortality measures - Coded data elements affecting Patient Safety Indicators - CDI impact on Hospital Value-Based Purchasing - Healthcare-associated infections and complication codes |
| Communication skills | 9.17% | - Physician education forms and tools - Roles and responsibilities of CDI specialists - Effective and non-confrontational physician communication - Roles and responsibilities of coders working with CDI departments - Reconciling CDI working DRGs with final coded DRGs - Educational presentations for healthcare departments and administration - Verbal versus written physician communication |
| Anatomy and physiology, pathophysiology, pharmacology, and medical terminology | 19.17% | - Diseases and disorders of the hepatobiliary system - Medications as clinical indicators - Clinical indicators and query opportunities by Major Diagnostic Category - Diseases and disorders of the nervous system - Diseases and disorders of the kidney and urinary tract - Mental diseases and disorders - Standard medical abbreviations - Pharmaceuticals and disease processes - Endocrine, nutritional, and metabolic diseases and disorders - Injuries, poisonings, and toxic effects of drugs - Diagnostic tests as clinical indicators - Infectious and parasitic diseases - Diseases and disorders of the skin, subcutaneous tissue, and breast - Diseases and disorders of the circulatory system - Diseases and disorders of the musculoskeletal system - Myeloproliferative diseases and disorders and poorly differentiated neoplasms - HIV infections - Alcohol/drug use and alcohol/drug-induced organic brain disorders - Diseases and disorders of the digestive system - Diseases and disorders of the respiratory system - Diseases and disorders of the blood and blood-forming organs and immunological disorders |
| Healthcare regulations, reimbursement, and documentation requirements related to the IPPS | 12.5% | - Medicare contractors and their impact on CDI - Medical staff and clinical staff documentation responsibilities - Major complication/comorbidity (MCC) - Case mix index (CMI) - Documentation and medical necessity of setting - Inpatient admission criteria and CMS Two-Midnight Rule - IPPS and its updates and revisions - Medicare Severity Diagnosis Related Groups (MS-DRGs) - Documentation impact on IPPS reimbursement - Principal diagnosis and medical necessity - Coding and billing practices vulnerable to denial - Complication/comorbidity (CC) |
| Healthcare facility CDI program analysis | 8.33% | - Patient Safety Indicators - Case mix index (CMI) - Physician performance measurement - Publicly reported data - Hospital Value-Based Purchasing measures - PEPPER data - Hospital-specific financial data - CDI program forecasting - Provider response rates - High-frequency DRGs - Basic computer and software application skills - Severity of illness and risk of mortality - Tracking and trending physician, department, and hospital performance - CDI specialist productivity metrics - CC/MCC capture |
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NEW QUESTION # 46
A patient is admitted with confusion and a history of alcoholic cirrhosis. Ammonia level is 100 µ/L and the blood alcohol level is 2.9. Based on these clinical indicators, the CDI specialist should query the physician for which of the following conditions?
Answer: A
Explanation:
Within the answer choices provided by the source question, hepatic failure is the intended clarification because the combination of cirrhosis, confusion, and markedly elevated ammonia suggests clinically significant hepatic dysfunction with an encephalopathic process.
The pathophysiologic concern is impaired hepatic detoxification and/or portosystemic shunting, allowing neurotoxins such as ammonia to accumulate and contribute to altered mental status. Other supportive findings can include asterixis, disorientation, somnolence, abnormal liver synthetic function, jaundice, ascites, and response to lactulose or rifaximin.
A crucial contemporary CDI distinction is that hepatic encephalopathy now has a dedicated ICD-10-CM code, K76.82. Therefore, current documentation practice should seek the diagnosis that most accurately represents the provider's clinical judgment-such as hepatic encephalopathy-rather than automatically equating elevated ammonia with hepatic failure. Hyperammonemia by itself is not diagnostic, and confusion can have multiple etiologies.
Alcohol dependence is addressed separately based on behavioral criteria, while alcohol poisoning requires evidence that the acute alcohol exposure is the cause of toxicity.
CCDS Reference Topics: Cirrhosis; hepatic dysfunction; hepatic encephalopathy; hyperammonemia; clinical validation and specificity.
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NEW QUESTION # 47
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: D
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 # 48
A patient with type 2 diabetes mellitus is admitted with stage 4 chronic kidney disease. The physician documents both conditions but does not explicitly state that the CKD is caused by diabetes. No documentation indicates that the conditions are unrelated. Which of the following is the MOST appropriate coding approach?
Answer: D
Explanation:
ICD-10-CM permits a presumed causal relationship between diabetes mellitus and certain conditions indexed under "diabetes, with," including chronic kidney disease. Therefore, when diabetes and CKD are both documented and the provider has not specifically indicated that they are unrelated, the diabetes-with-CKD combination code is assigned together with an additional code identifying the CKD stage.
For type 2 diabetes, diabetic CKD is classified to E11.22, while an N18.- code identifies the documented CKD stage. In this scenario, stage 4 CKD would be additionally represented by the appropriate stage-specific N18 code.
A query is not routinely necessary simply to obtain wording such as "diabetic CKD" when the classification itself establishes the presumed relationship. However, clarification would be appropriate if documentation explicitly states another unrelated etiology or contains contradictory information.
This distinction is important for CDI because excessive querying can create unnecessary provider burden.
CDI specialists must understand which diagnostic relationships require explicit provider linkage and which are established through ICD-10-CM conventions.
The FY 2026 Official Guidelines remain applicable to discharges through September 30, 2026.
CCDS Reference Topics: Diabetes; CKD; presumed causal relationships; combination codes; coding conventions.
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NEW QUESTION # 49
A hospital has a total MS-DRG relative weight of 2,640 for 1,600 inpatient discharges. What is its case mix index?
Answer: D
Explanation:
Case mix index is calculated by dividing the sum of MS-DRG relative weights by the number of inpatient discharges:
2,640 ÷ 1,600 = 1.65
Therefore, the CMI is 1.65.
CMI represents the average relative resource intensity of the hospital's inpatient cases. It is affected by the types of patients treated, surgical versus medical mix, tertiary services, transplant or trauma volume, documentation specificity, coding accuracy, and annual changes to MS-DRG relative weights and grouper logic.
CMS publishes hospital case-mix information and FY 2026 relative weighting factors through the IPPS Final Rule supporting data. Table 5 contains MS-DRGs and relative weighting factors, while Table 2 contains hospital-specific case-mix information.
A decline in CMI should not automatically be interpreted as a CDI failure. A shift toward lower-complexity cases or changes in service lines can legitimately reduce CMI even with excellent documentation.
CDI managers should therefore trend CMI alongside diagnosis capture, surgical volume, service lines, payer population, coding reconciliation, and quality indicators.
CCDS Reference Topics: Case mix index; MS-DRG relative weight; CDI analytics; hospital performance.
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NEW QUESTION # 50
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: C
Explanation:
When sepsis due to a localized infection is responsible for the admission, the systemic infection is generally sequenced first, followed by the localized infection. If acute organ dysfunction is documented as associated with the sepsis, severe sepsis coding additionally requires the appropriate R65.2- code and code(s) for the acute organ dysfunction.
The severe-sepsis code itself is not sequenced as principal diagnosis. The underlying systemic infection precedes it. In this case, the patient's AKI has specifically been linked to sepsis, supporting the severe-sepsis framework.
Pneumonia remains important because it identifies the localized source of infection, but it does not generally precede the systemic infection when sepsis is present on admission and is responsible for the hospitalization.
The CDI specialist should verify that the documentation clearly establishes the relationship between the acute organ dysfunction and sepsis. Organ dysfunction occurring in a patient with sepsis is not automatically attributable to sepsis when another cause is documented or clinically plausible.
The FY 2026 ICD-10-CM Official Guidelines govern these sequencing principles.
CCDS Reference Topics: Sepsis; severe sepsis; principal diagnosis; acute organ dysfunction; sequencing.
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NEW QUESTION # 51
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