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| Section | Weight | Objectives |
|---|---|---|
| Topic 1: Healthcare regulations, reimbursement, and documentation requirements related to the IPPS | 12.5% | - Coding and billing practices vulnerable to denial - Medicare contractors and their impact on CDI - Complication/comorbidity (CC) - Documentation and medical necessity of setting - Inpatient admission criteria and CMS Two-Midnight Rule - Medicare Severity Diagnosis Related Groups (MS-DRGs) - Case mix index (CMI) - Major complication/comorbidity (MCC) - Documentation impact on IPPS reimbursement - Medical staff and clinical staff documentation responsibilities - IPPS and its updates and revisions - Principal diagnosis and medical necessity |
| Topic 2: Professionalism, ethics, and compliance | 9.17% | - Potential DRG creep - Leading queries - Medical record confidentiality - CDI department goals beyond reimbursement - Compliance risks indicated by PEPPER - DRG compliance initiatives |
| Topic 3: Official Guidelines for Coding and Reporting | 14.17% | - Secondary diagnosis assignment - Working DRG assignment for multiple diagnoses - Discharge dispositions and transfers - Present on admission indicators - AHA Coding Clinic - Official Guidelines for Coding and Reporting updates - Coding guidelines for principal diagnosis selection - Hospital-acquired conditions - Principal diagnosis assignment |
| Topic 4: Anatomy and physiology, pathophysiology, pharmacology, and medical terminology | 19.17% | - Infectious and parasitic diseases - Clinical indicators and query opportunities by Major Diagnostic Category - Pharmaceuticals and disease processes - Diseases and disorders of the nervous system - HIV infections - Diseases and disorders of the digestive system - Standard medical abbreviations - Medications as clinical indicators - Myeloproliferative diseases and disorders and poorly differentiated neoplasms - Diseases and disorders of the kidney and urinary tract - Endocrine, nutritional, and metabolic diseases and disorders - Diseases and disorders of the hepatobiliary system - Injuries, poisonings, and toxic effects of drugs - Diseases and disorders of the blood and blood-forming organs and immunological disorders - Diseases and disorders of the skin, subcutaneous tissue, and breast - Diseases and disorders of the musculoskeletal system - Diagnostic tests as clinical indicators - Alcohol/drug use and alcohol/drug-induced organic brain disorders - Mental diseases and disorders - Diseases and disorders of the respiratory system - Diseases and disorders of the circulatory system |
| Topic 5: Healthcare facility CDI program analysis | 8.33% | - Provider response rates - Hospital-specific financial data - Basic computer and software application skills - Case mix index (CMI) - Hospital Value-Based Purchasing measures - CC/MCC capture - High-frequency DRGs - PEPPER data - Physician performance measurement - Severity of illness and risk of mortality - CDI specialist productivity metrics - Patient Safety Indicators - Publicly reported data - CDI program forecasting - Tracking and trending physician, department, and hospital performance |
| Topic 6: Communication skills | 9.17% | - Educational presentations for healthcare departments and administration - Physician education forms and tools - Reconciling CDI working DRGs with final coded DRGs - Verbal versus written physician communication - Effective and non-confrontational physician communication - Roles and responsibilities of coders working with CDI departments - Roles and responsibilities of CDI specialists |
| Topic 7: Impact of reportable diagnoses on quality of care | 8.33% | - Hospital-Acquired Condition Reduction Program - Coded data elements affecting Patient Safety Indicators - CDI impact on Hospital Value-Based Purchasing - Hospital Value-Based Purchasing - Hospital Inpatient Quality Reporting Program - Healthcare-associated infections and complication codes - Mortality reviews and observed/expected ratios - Hospital Readmissions Reduction Program - Quality data from record abstraction and claims data - Documentation and code assignment impact on mortality index - Patient Safety Indicators - 30-day mortality measures |
| Topic 8: Medical record documentation | 19.17% | - ACDIS/AHIMA Guidelines for Achieving a Compliant Query Practice - Addressing diagnoses without clinical support - Provider role and diagnosis code assignment - Physician query formats - Clinical indicators - Compliant and noncompliant queries - Health record elements used for diagnosis and procedure code assignment - Types of physician queries - When a physician query is warranted - Translating clinical indicators into compliant queries - Documentation requiring clarification - Situations in which queries are not appropriate |
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NEW QUESTION # 25
A patient has chronic gastroesophageal reflux disease listed in the past medical history. During the current hospitalization for bacterial pneumonia, GERD receives no clinical evaluation, treatment, diagnostic testing, increased nursing monitoring, or effect on length of stay. Which statement is MOST accurate?
Answer: B
Explanation:
A condition documented in the medical record does not automatically qualify as a reportable secondary diagnosis. For inpatient coding, additional diagnoses generally must be clinically significant during the current hospitalization. Qualifying significance includes clinical evaluation, therapeutic treatment, diagnostic procedures, an extended length of stay, or increased nursing care and/or monitoring.
Here, GERD is merely part of the patient's historical medical background and does not affect current management. Therefore, it generally should not be reported as an additional diagnosis solely because it appears in the past medical history.
Whether a diagnosis is classified as a CC or MCC is a separate issue. A condition must first satisfy applicable reporting requirements before its MS-DRG severity classification matters. CDI specialists should never encourage coding of clinically irrelevant historical conditions merely because they could affect reimbursement.
This principle protects the clinical integrity of coded data and prevents inappropriate inflation of disease burden. CDI review should focus on conditions that meaningfully describe the patient's current hospitalization, treatment requirements, clinical risk, and resource consumption.
CCDS Reference Topics: Reporting additional diagnoses; secondary-diagnosis criteria; medical-record review; resource utilization; coding compliance.
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NEW QUESTION # 26
A patient accidentally takes twice the prescribed dose of warfarin and develops gastrointestinal bleeding.
Which coding concept applies?
Answer: A
Explanation:
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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NEW QUESTION # 27
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: A
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 # 28
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?
Answer: D
Explanation:
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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NEW QUESTION # 29
A patient with a history of heart failure is admitted with severe dyspnea and bilateral lower-extremity edema.
BNP is 1,000 pg/mL and echocardiography shows an ejection fraction of 25% with left ventricular systolic dysfunction. Which diagnosis should the CDI specialist consider when constructing a clinically supported clarification query?
Answer: D
Explanation:
Acute on chronic systolic heart failure is the intended answer. This scenario is adapted from an official ACDIS CCDS sample question, which uses dyspnea, edema, elevated BNP, reduced ejection fraction, and left- ventricular dysfunction to test appropriate heart-failure clarification.
The ejection fraction of 25% and documented left ventricular systolic dysfunction support a systolic phenotype. The patient's significant dyspnea and edema are consistent with acute decompensation superimposed on the established history of heart failure. Together, these findings create a legitimate opportunity to clarify type and acuity.
The CDI specialist must nevertheless avoid diagnosing acute-on-chronic systolic failure independently. The provider determines whether the findings represent acute decompensation, chronic disease, another heart- failure phenotype, or another explanation entirely.
Option A would require evidence supporting both systolic and diastolic dysfunction. Option B fails to capture the apparent acute decompensation. Option D conflicts with the documented systolic dysfunction and reduced EF.
This question illustrates a frequent CCDS theme: translating clinical indicators into a neutral clarification opportunity rather than assigning a diagnosis based solely on test results.
CCDS Reference Topics: Heart-failure acuity and type; ejection fraction; BNP; compliant query development.
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NEW QUESTION # 30
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