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| Section | Weight | Objectives |
|---|---|---|
| Topic 1: Healthcare facility CDI program analysis | 8.33% | - Data analysis, forecasting, and performance measurement - CDI productivity, provider response, CMI, and program metrics |
| Topic 2: Medical record documentation | 19.17% | - Documentation clarification and compliant physician queries - Documentation requirements and diagnosis or procedure code assignment |
| Topic 3: Anatomy and physiology, pathophysiology, pharmacology, and medical terminology | 19.17% | - Clinical conditions and clinical indicators - Anatomy, physiology, pathophysiology, pharmacology, and terminology |
| Topic 4: Communication skills | 9.17% | - Physician education and effective communication - CDI and coding roles and interdisciplinary collaboration |
| Topic 5: Official Guidelines for Coding and Reporting | 14.17% | - Principal and secondary diagnosis assignment - Coding guidelines, AHA Coding Clinic, HACs, and POA indicators |
| Topic 6: Impact of reportable diagnoses on quality of care | 8.33% | - Quality metrics, reporting programs, and financial impact - Mortality, severity of illness, and risk of mortality |
| Topic 7: Professionalism, ethics, and compliance | 9.17% | - Query compliance, DRG creep, and audit risks - Confidentiality, DRG compliance, and ethical CDI practices |
| Topic 8: Healthcare regulations, reimbursement, and documentation requirements related to the IPPS | 12.5% | - IPPS, MS-DRGs, reimbursement, and medical necessity - CC/MCC, CMI, Medicare contractors, and compliance |
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37. Frage
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?
Antwort: A
Begründung:
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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38. Frage
A CDI specialist identifies a diagnosis that would change the case from a lower-weight MS-DRG to a higher- weight MS-DRG. The medical record contains no clinical indicators supporting that diagnosis. What is the BEST action?
Antwort: B
Begründung:
A query should not be issued solely because a diagnosis would increase reimbursement when the record contains no clinical basis for that diagnosis.
The 2026 ACDIS/AHIMA compliant-query guidance establishes that CDI clarification must be grounded in the patient's clinical record and directed toward ensuring accurate representation of clinical status. The updated guidance supersedes all previous versions and applies across CDI and coding environments.
Financial impact may occur as a consequence of accurate documentation, but it cannot be the clinical rationale for introducing an unsupported condition. A query containing a single unsupported diagnosis would also risk being leading or otherwise noncompliant.
Likewise, a coder cannot provisionally manufacture a diagnosis simply because it would affect the MS-DRG.
Code assignment depends on the documented clinical record and applicable coding conventions.
This principle applies equally in the opposite direction: if clarification could reduce reimbursement but is necessary to correct inaccurate, conflicting, or unsupported documentation, CDI should still pursue clarification. Effective CDI programs protect the integrity of the health record, not a predetermined financial outcome.
CCDS Reference Topics: Ethics; query compliance; clinical support; reimbursement neutrality; documentation integrity.
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39. Frage
A patient develops a surgical-site infection after abdominal surgery and is admitted with sepsis. The surgeon clearly documents "sepsis due to postoperative wound infection." Which diagnosis category is generally sequenced first?
Antwort: C
Begründung:
Sepsis resulting from a postprocedural infection follows specialized sequencing rules. The code identifying the postprocedural infection or surgical-site infection is sequenced first when applicable, followed by the code for sepsis following a procedure and any additional codes required for the infectious organism or severe sepsis.
The FY 2026 Official Guidelines specifically state that for sepsis following a postprocedural wound or surgical-site infection, the appropriate postprocedural infection code is sequenced first. An additional code for sepsis following a procedure is then assigned. If severe sepsis exists, the appropriate R65.2- code and codes for acute organ dysfunction are additionally reported.
This differs from ordinary sepsis due to a localized infection, where the systemic infection is typically sequenced before the localized infection when sepsis is the reason for admission.
The cause-and-effect relationship is also essential. A wound infection merely occurring after surgery does not automatically establish a postprocedural complication. Here, the surgeon has explicitly documented that relationship, so the necessary clinical linkage is present.
CCDS Reference Topics: Postprocedural infection; sepsis; surgical-site infection; complication coding; sequencing.
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40. Frage
A CDI program reports the following monthly results:
- Provider response rate: 97%
- Provider agreement rate: 84%
- Queries issued after discharge: 38%
- CDI/coder agreement: 96%
Which metric presents the clearest opportunity to improve concurrent CDI workflow?
Antwort: A
Begründung:
The 38% post-discharge query rate represents the clearest workflow opportunity because a large proportion of clarification is occurring after the concurrent hospitalization period.
A 97% provider response rate reflects strong physician participation, while a 96% CDI/coder agreement rate indicates substantial alignment between concurrent CDI review and final coding. An 84% agreement rate is not inherently problematic because providers must remain free to disagree with a query based on their clinical judgment.
A high retrospective-query percentage can indicate that cases are being reviewed too late, that certain documentation opportunities are not recognized during hospitalization, that discharge documentation introduces unresolved diagnoses, or that staffing/workflow does not adequately prioritize cases before discharge.
A CDI manager should drill further into the metric by service line, query type, day of stay, weekday/weekend discharge, provider group, and reason for retrospective clarification. This analysis helps distinguish unavoidable retrospective queries from remediable process problems.
The objective is not to eliminate every post-discharge query. Some documentation issues become apparent only after final testing, pathology, procedures, or discharge summaries are completed.
CCDS Reference Topics: CDI program metrics; concurrent versus retrospective review; workflow analysis; performance improvement.
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41. Frage
Documentation indicates an excisional debridement was performed without further specification. The CDI specialist should query to clarify which of the following?
Antwort: B
Begründung:
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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42. Frage
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