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| Section | Weight | Objectives |
|---|---|---|
| Topic 1: Communication skills | 9.17% | - Physician education forms and tools - Educational presentations for healthcare departments and administration - Roles and responsibilities of CDI specialists - Roles and responsibilities of coders working with CDI departments - Verbal versus written physician communication - Reconciling CDI working DRGs with final coded DRGs - Effective and non-confrontational physician communication |
| Topic 2: Professionalism, ethics, and compliance | 9.17% | - Leading queries - Potential DRG creep - Medical record confidentiality - DRG compliance initiatives - Compliance risks indicated by PEPPER - CDI department goals beyond reimbursement |
| Topic 3: Official Guidelines for Coding and Reporting | 14.17% | - Working DRG assignment for multiple diagnoses - Discharge dispositions and transfers - Coding guidelines for principal diagnosis selection - AHA Coding Clinic - Hospital-acquired conditions - Secondary diagnosis assignment - Present on admission indicators - Official Guidelines for Coding and Reporting updates - Principal diagnosis assignment |
| Topic 4: Healthcare facility CDI program analysis | 8.33% | - Basic computer and software application skills - Physician performance measurement - Case mix index (CMI) - High-frequency DRGs - Provider response rates - Publicly reported data - CDI program forecasting - CC/MCC capture - Hospital-specific financial data - Patient Safety Indicators - PEPPER data - Tracking and trending physician, department, and hospital performance - Hospital Value-Based Purchasing measures - Severity of illness and risk of mortality - CDI specialist productivity metrics |
| Topic 5: Anatomy and physiology, pathophysiology, pharmacology, and medical terminology | 19.17% | - Medications as clinical indicators - Diseases and disorders of the kidney and urinary tract - Clinical indicators and query opportunities by Major Diagnostic Category - Diseases and disorders of the nervous system - Alcohol/drug use and alcohol/drug-induced organic brain disorders - Myeloproliferative diseases and disorders and poorly differentiated neoplasms - 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 circulatory system - Endocrine, nutritional, and metabolic diseases and disorders - Diagnostic tests as clinical indicators - Diseases and disorders of the musculoskeletal system - Standard medical abbreviations - Diseases and disorders of the skin, subcutaneous tissue, and breast - Pharmaceuticals and disease processes - Diseases and disorders of the respiratory system - Diseases and disorders of the hepatobiliary system - Diseases and disorders of the digestive system - Mental diseases and disorders - Infectious and parasitic diseases - HIV infections |
| Topic 6: Impact of reportable diagnoses on quality of care | 8.33% | - Hospital Value-Based Purchasing - CDI impact on Hospital Value-Based Purchasing - Hospital Inpatient Quality Reporting Program - Documentation and code assignment impact on mortality index - Healthcare-associated infections and complication codes - Quality data from record abstraction and claims data - Patient Safety Indicators - Hospital Readmissions Reduction Program - 30-day mortality measures - Hospital-Acquired Condition Reduction Program - Mortality reviews and observed/expected ratios - Coded data elements affecting Patient Safety Indicators |
| Topic 7: Healthcare regulations, reimbursement, and documentation requirements related to the IPPS | 12.5% | - Inpatient admission criteria and CMS Two-Midnight Rule - Major complication/comorbidity (MCC) - Principal diagnosis and medical necessity - Complication/comorbidity (CC) - Case mix index (CMI) - Documentation impact on IPPS reimbursement - Coding and billing practices vulnerable to denial - Documentation and medical necessity of setting - IPPS and its updates and revisions - Medicare contractors and their impact on CDI - Medical staff and clinical staff documentation responsibilities - Medicare Severity Diagnosis Related Groups (MS-DRGs) |
| Topic 8: Medical record documentation | 19.17% | - Documentation requiring clarification - Provider role and diagnosis code assignment - Types of physician queries - When a physician query is warranted - Compliant and noncompliant queries - Translating clinical indicators into compliant queries - Physician query formats - Addressing diagnoses without clinical support - Health record elements used for diagnosis and procedure code assignment - Clinical indicators - Situations in which queries are not appropriate - ACDIS/AHIMA Guidelines for Achieving a Compliant Query Practice |
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NEW QUESTION # 18
The attending physician documents "acute systolic heart failure," while a consultant documents "chronic diastolic heart failure" for the same episode of care. Which provider should ultimately clarify the conflicting diagnostic documentation for coding purposes?
Answer: C
Explanation:
The attending physician is the correct answer and this scenario is adapted from an official ACDIS CCDS sample item addressing conflicting medical-record documentation.
ICD-10-CM coding depends on provider documentation, but when clinically significant documentation conflicts within the record, the discrepancy must be clarified rather than resolved independently by the coder or CDI specialist. The FY 2026 Official Guidelines specifically state that when medical-record documentation conflicts, the patient's provider should be queried for clarification.
In the inpatient environment, the attending provider is generally responsible for synthesizing the patient's diagnoses and final clinical picture. A consultant's documentation may supply essential clinical information and may support code assignment when there is no conflict, but conflicting descriptions of heart-failure type or acuity should not simply be selected based on which diagnosis produces the higher-severity code.
The query should identify the conflicting statements objectively and request clarification of the clinically appropriate diagnosis. It should not suggest which diagnosis should be selected or mention reimbursement consequences.
This concept is central to CDI because unresolved contradictions can affect MS-DRG assignment, risk adjustment, severity measurement, quality reporting, and the clinical integrity of the record.
CCDS Reference Topics: Conflicting documentation; provider clarification; heart-failure specificity; medical-record integrity.
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NEW QUESTION # 19
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: A
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 # 20
A patient was admitted with weakness, loss of appetite, hemoglobin 7.8, WBC 2,700, and platelet count 58.
The admitting diagnoses on the history and physical were anemia, leukopenia, decreased platelets, and rule out myelodysplastic syndrome. Based on these clinical indicators a CDI specialist should query for which of the following conditions?
Answer: D
Explanation:
The laboratory findings demonstrate reduction in all three major peripheral blood-cell lines: hemoglobin 7.8 indicates anemia, WBC 2,700 indicates leukopenia, and platelets 58 indicate thrombocytopenia. Collectively, this pattern is consistent with pancytopenia, making option C the most appropriate documentation clarification.
The National Cancer Institute defines pancytopenia as a lower-than-normal number of red blood cells, white blood cells, and platelets. Importantly, pancytopenia describes the hematologic state; it does not establish its underlying etiology. Myelodysplastic syndrome was only being ruled out in the scenario, so the CDI specialist should not infer it as the definitive cause.
Thrombocytopenia alone would capture only one component of the abnormal CBC and would fail to represent the simultaneous anemia and leukopenia. Myelophthisis implies marrow displacement or infiltration and cannot be inferred from these counts alone. Likewise, aplastic anemia is a specific bone-marrow failure diagnosis requiring provider determination and supporting diagnostic evaluation.
A compliant query can present pancytopenia as a clinically supported choice while allowing the provider to document another explanation.
CCDS Reference Topics: Hematology; clinical indicators; medical terminology; compliant query opportunity.
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NEW QUESTION # 21
A 91-year-old has a past medical history of heart failure, COPD, and adenocarcinoma of the lung and brain.
The patient presents with shortness of breath, weakness, and pain. His vital signs are T 99°F, RR 18, BP 108
/74, and pulse 110. Pulse oximetry is 98% on 2 L nasal cannula. He is admitted with HCAP, COPD, and diastolic heart failure.
Initial laboratory values are:
Hgb: 9.0
Sodium: 134.0
WBC: 12.9
The physician orders antibiotics and 2 L nasal cannula. Based upon the information provided above, which of the following queries would be MOST appropriate?
Answer: A
Explanation:
The most appropriate clarification concerns the underlying cause/type of pneumonia. The record documents
"HCAP," but that term does not identify a specific causative organism or pathophysiologic pneumonia type.
The patient is being actively treated with antibiotics, has leukocytosis, and was admitted with pneumonia- related documentation, creating a legitimate opportunity to clarify clinically supported specificity.
The other options are weaker. Hemoglobin of 9.0 supports anemia but does not establish acute blood loss anemia without evidence of active/recent blood loss or an acute decline. Sodium of 134 mEq/L is only mildly reduced and, without treatment or other clinical significance, does not by itself justify seeking a diagnosis solely from the laboratory value.
The record already specifies diastolic heart failure. Although acuity could sometimes warrant clarification, the presented findings do not strongly establish acute decompensated heart failure: oxygen requirement is modest, saturation is 98%, and no pulmonary edema, diuretic escalation, or other acute HF indicators are provided.
The query should remain neutral and allow the provider to identify the pneumonia type only if clinically determinable.
CCDS Reference Topics: Pneumonia specificity; clinical indicators; documentation clarification; query prioritization.
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NEW QUESTION # 22
Documentation indicates an excisional debridement was performed without further specification. The CDI specialist should query to clarify which of the following?
Answer: A
Explanation:
The most critical missing element is the depth or level of tissue actually debrided. Documentation of an excisional debridement should identify whether tissue removed included skin, subcutaneous tissue, fascia, muscle, bone, or another anatomical layer. The level removed is fundamental to accurate procedural classification and coding.
CMS wound-care documentation standards similarly emphasize that the medical record should describe the type and depth of tissue removed. Merely knowing that an excisional debridement occurred does not establish the anatomical level of the procedure.
The instrument may provide useful procedural context-for example, scalpel, scissors, curette, or other technique-but the instrument alone does not identify the deepest tissue excised. Wound size can be important for clinical care and certain coding systems, but it does not replace documentation of the tissue level removed. The identity of the person performing the procedure is also part of procedural documentation but does not answer the principal coding-specific deficiency in this scenario.
A CDI query should therefore seek the deepest tissue level actually excised rather than infer it from the wound's overall depth.
CCDS Reference Topics: Medical record documentation; ICD-10-PCS/procedure documentation; debridement specificity.
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NEW QUESTION # 23
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