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| Section | Weight | Objectives |
|---|---|---|
| CDI Program Management & Professional Practice | 15% | - Provider education and training strategies - Program metrics, benchmarks, and performance measurement - Ethics, HIPAA, and professional conduct |
| Clinical Documentation Review & Query Practices | 20% | - Query development, communication, and ethical standards - Concurrent and retrospective chart review methodologies - Documentation gap identification and resolution |
| Coding Guidelines & Official Reporting Standards | 15% | - AHIMA/ACDIS Guidelines for Compliant Query Practice - ICD-10-CM/PCS Official Guidelines for Coding and Reporting - Coding integrity and compliant documentation practices |
| Quality, Risk Adjustment & Health Initiatives | 15% | - Risk adjustment models and documentation impact - Quality reporting, public reporting, and compliance programs - Severity of Illness (SOI) / Risk of Mortality (ROM) |
| Clinical Knowledge & Disease Processes Application | 20% | - Clinical indicators, lab results, medications, diagnostic findings - Disease processes across body systems applied to chart review - Medical terminology, anatomy, physiology, pathophysiology |
| Healthcare Regulations, Reimbursement & Documentation Requirements – IPPS | 15% | - Medicare Severity Diagnostic Related Groups (MS-DRGs) - Documentation responsibilities of medical and clinical staff - Inpatient Prospective Payment System (IPPS) fundamentals |
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NEW QUESTION # 119
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: D
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 # 120
A wound care nurse documents an assessment and care of a pressure ulcer. For coding purposes, the wound care nurse's documentation can be used to assign which of the following?
Answer: C
Explanation:
The wound care nurse's documentation may be used to establish the stage of a pressure ulcer, making option D correct. ICD-10-CM provides specific exceptions to the general rule that diagnosis code assignment is based on documentation by a provider legally accountable for establishing diagnoses. Pressure-ulcer staging is one of the clinical details that may be derived from documentation by qualified non-provider clinicians involved in the patient's care.
Wound care nurses possess specialized expertise in pressure-injury assessment and commonly document staging based on tissue involvement. Current ICD-10-CM guidance directs assignment of the pressure-ulcer stage according to clinical documentation and provides specific rules for unstageable ulcers, healing ulcers, and ulcers that progress during hospitalization.
This exception does not mean that a wound-care nurse independently establishes every element of the medical diagnosis for coding purposes. The provider documentation remains central to identifying the pressure-ulcer diagnosis and relevant clinical condition, while the stage may come from qualified clinician documentation.
POA assignment follows separate reporting rules and is based on whether the condition was present at the time inpatient admission occurred.
CCDS Reference Topics: Pressure ulcers; non-provider documentation; staging; coding conventions.
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NEW QUESTION # 121
A hospital's mortality report shows 125 observed deaths and 100 expected deaths. The observed-to-expected mortality ratio is 1.25. Which interpretation is MOST accurate?
Answer: A
Explanation:
An observed-to-expected mortality ratio is calculated by dividing observed deaths by expected deaths. Here,
125 divided by 100 equals 1.25. Therefore, observed deaths are 25% higher than the number predicted by the risk-adjustment model.
A ratio of 1.0 indicates observed mortality equals expected mortality. A value below 1.0 indicates fewer observed deaths than predicted, while a value above 1.0 indicates more observed deaths than predicted.
The CDI implication is important. Expected mortality is influenced by the patient's documented disease burden and other variables used by the applicable risk-adjustment methodology. If clinically significant conditions are underdocumented, the coded record may fail to represent the patient's actual severity, potentially reducing calculated expected mortality.
However, CDI should never seek diagnoses solely to improve a mortality ratio. Each diagnosis must be clinically supported and accurately documented. A high ratio can reflect multiple factors-including clinical outcomes, case mix, documentation, coding, data quality, or model characteristics-and should trigger multidisciplinary analysis rather than automatic querying.
ACDIS includes mortality and severity/risk adjustment within CCDS competency expectations.
CCDS Reference Topics: O/E mortality; risk adjustment; severity documentation; quality outcomes.
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NEW QUESTION # 122
A patient is admitted with sepsis due to osteomyelitis and evidence of organ failure. Which of the following is the correct principal diagnosis?
Answer: D
Explanation:
The underlying systemic infection/sepsis code is sequenced as the principal diagnosis when sepsis or severe sepsis is present on admission and is the condition chiefly responsible for admission. Therefore, sepsis is the correct selection from the available choices.
The presence of organ failure means the patient may also meet the documentation requirements for severe sepsis when the acute organ dysfunction is explicitly associated with the sepsis. However, the severe-sepsis code from subcategory R65.2- cannot be assigned as the principal diagnosis. The FY 2026 ICD-10-CM Official Guidelines require the underlying systemic infection first, followed by R65.2- and codes for the associated acute organ dysfunction.
Osteomyelitis represents the localized infection source, but when the reason for admission is sepsis associated with that localized infection, the systemic infection is sequenced first under the sepsis guidelines.
"Septicemia" should not be substituted for provider-documented sepsis.
The CDI specialist should also verify that the provider has clearly linked the organ failure to sepsis before severe-sepsis coding is applied.
CCDS Reference Topics: Sepsis sequencing; severe sepsis; principal diagnosis; localized infection.
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NEW QUESTION # 123
A pregnant female presents to the ED with diarrhea, cramps, nausea, and vomiting for the past 12 hours. She was admitted with enteritis due to Clostridium difficile and provided IV fluids. Which of the following coding guidelines applies to determining the principal diagnosis for this patient?
Answer: B
Explanation:
For a pregnant patient, the first coding consideration is the Chapter 15 obstetric guideline unless the provider explicitly documents that the pregnancy is incidental to the encounter. ICD-10-CM codes from O00-O9A have sequencing priority over codes from other chapters when a condition complicates pregnancy, childbirth, or the puerperium.
Therefore, although the patient's underlying clinical disease is Clostridium difficile enteritis, the principal- diagnosis analysis begins with the applicable pregnancy-complication code. An additional infectious-disease code would then be used as appropriate to identify the specific infection. The infectious and parasitic disease chapter does not override the obstetric sequencing rules.
Signs such as diarrhea, cramps, nausea, and vomiting are also not the principal coding focus once a definitive diagnosis-C. difficile enteritis-has been established. Similarly, an etiology/manifestation sequencing convention is not the controlling rule in this scenario.
The critical CCDS concept is recognition of chapter-specific sequencing rules. A CDI specialist reviewing pregnant patients must recognize that otherwise standard principal-diagnosis logic may be superseded by obstetric instructions.
CCDS Reference Topics: Official Guidelines for Coding and Reporting-Chapter 15; principal diagnosis selection; chapter-specific sequencing.
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NEW QUESTION # 124
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