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| Section | Weight | Objectives |
|---|---|---|
| Communication skills | 9.17% | - Reconciling CDI working DRGs with final coded DRGs - Roles and responsibilities of coders working with CDI departments - Roles and responsibilities of CDI specialists - Educational presentations for healthcare departments and administration - Effective and non-confrontational physician communication - Physician education forms and tools - Verbal versus written physician communication |
| Medical record documentation | 19.17% | - ACDIS/AHIMA Guidelines for Achieving a Compliant Query Practice - Physician query formats - Health record elements used for diagnosis and procedure code assignment - Provider role and diagnosis code assignment - Types of physician queries - Addressing diagnoses without clinical support - When a physician query is warranted - Translating clinical indicators into compliant queries - Clinical indicators - Documentation requiring clarification - Compliant and noncompliant queries - Situations in which queries are not appropriate |
| Healthcare facility CDI program analysis | 8.33% | - Provider response rates - PEPPER data - Severity of illness and risk of mortality - Publicly reported data - CC/MCC capture - Hospital Value-Based Purchasing measures - Tracking and trending physician, department, and hospital performance - Case mix index (CMI) - Basic computer and software application skills - CDI specialist productivity metrics - Physician performance measurement - Hospital-specific financial data - High-frequency DRGs - Patient Safety Indicators - CDI program forecasting |
| Official Guidelines for Coding and Reporting | 14.17% | - Present on admission indicators - Official Guidelines for Coding and Reporting updates - Principal diagnosis assignment - Discharge dispositions and transfers - Working DRG assignment for multiple diagnoses - AHA Coding Clinic - Coding guidelines for principal diagnosis selection - Hospital-acquired conditions - Secondary diagnosis assignment |
| Healthcare regulations, reimbursement, and documentation requirements related to the IPPS | 12.5% | - Documentation and medical necessity of setting - Complication/comorbidity (CC) - IPPS and its updates and revisions - Medicare Severity Diagnosis Related Groups (MS-DRGs) - Inpatient admission criteria and CMS Two-Midnight Rule - Case mix index (CMI) - Medicare contractors and their impact on CDI - Principal diagnosis and medical necessity - Coding and billing practices vulnerable to denial - Major complication/comorbidity (MCC) - Documentation impact on IPPS reimbursement - Medical staff and clinical staff documentation responsibilities |
| Anatomy and physiology, pathophysiology, pharmacology, and medical terminology | 19.17% | - Diseases and disorders of the respiratory system - Diagnostic tests as clinical indicators - Mental diseases and disorders - Myeloproliferative diseases and disorders and poorly differentiated neoplasms - Injuries, poisonings, and toxic effects of drugs - Diseases and disorders of the musculoskeletal system - Clinical indicators and query opportunities by Major Diagnostic Category - Endocrine, nutritional, and metabolic diseases and disorders - Diseases and disorders of the digestive system - Diseases and disorders of the blood and blood-forming organs and immunological disorders - Diseases and disorders of the nervous system - Pharmaceuticals and disease processes - Standard medical abbreviations - Diseases and disorders of the hepatobiliary system - Infectious and parasitic diseases - HIV infections - Diseases and disorders of the circulatory system - Alcohol/drug use and alcohol/drug-induced organic brain disorders - Medications as clinical indicators - Diseases and disorders of the skin, subcutaneous tissue, and breast - Diseases and disorders of the kidney and urinary tract |
| Impact of reportable diagnoses on quality of care | 8.33% | - Coded data elements affecting Patient Safety Indicators - CDI impact on Hospital Value-Based Purchasing - Documentation and code assignment impact on mortality index - Hospital-Acquired Condition Reduction Program - Quality data from record abstraction and claims data - 30-day mortality measures - Hospital Readmissions Reduction Program - Healthcare-associated infections and complication codes - Hospital Value-Based Purchasing - Hospital Inpatient Quality Reporting Program - Patient Safety Indicators - Mortality reviews and observed/expected ratios |
| Professionalism, ethics, and compliance | 9.17% | - Compliance risks indicated by PEPPER - Medical record confidentiality - Potential DRG creep - Leading queries - DRG compliance initiatives - CDI department goals beyond reimbursement |
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NEW QUESTION # 30
When a physician documents the abbreviation "HCAP" in the health record, the BEST action for a CDI specialist to take is to:
Answer: A
Explanation:
The CDI specialist should seek greater specificity regarding the pneumonia. The abbreviation HCAP historically referred to "healthcare-associated pneumonia," but that terminology does not identify a causative organism or a sufficiently specific ICD-10-CM pneumonia diagnosis.
From a CDI perspective, the clinically relevant clarification may involve whether the pneumonia is bacterial, viral, aspiration-related, gram-negative, due to a specific organism, or otherwise characterized by the provider based on the available evidence. Culture results, aspiration risk, recent healthcare exposure, antibiotic selection, radiology, respiratory cultures, and infectious-disease documentation may provide appropriate clinical indicators for a neutral query.
Simply assigning a generic pneumonia working code fails to resolve the documentation deficiency. Asking only whether HCAP means "healthcare-acquired pneumonia" merely expands the abbreviation without producing useful etiologic specificity. "Complex pneumonia" is not an appropriate substitute diagnostic classification.
The CDI specialist must also avoid assuming that recent healthcare exposure establishes resistant-organism pneumonia. Contemporary clinical practice has moved away from treating HCAP as a standalone etiologic category because exposure alone does not reliably establish a particular pathogen.
CCDS Reference Topics: Pneumonia specificity; abbreviations; diagnostic clarification; compliant provider queries.
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NEW QUESTION # 31
A physician writes, "respiratory failure following surgery." The patient required mechanical ventilation for several hours after a prolonged major operation, and anesthesia documentation indicates this was an anticipated part of postoperative recovery. What is the BEST CDI action?
Answer: D
Explanation:
The CDI specialist should clarify the clinical significance and relationship to the procedure. Not every condition occurring after surgery constitutes a complication of care, and mechanical ventilation itself does not establish postoperative respiratory failure.
Major operations often require planned postoperative ventilatory support because of anesthesia, surgical duration, hemodynamic status, or other expected recovery needs. Conversely, unexpected inability to extubate, severe hypoxemia or hypercapnia, escalating ventilatory support, or other clinical deterioration may support a genuine postoperative respiratory complication.
ICD-10-CM complication reporting requires careful attention to provider documentation of the relationship between the condition and the procedure. The FY 2026 Official Guidelines emphasize that the fact a condition occurs after a procedure is not, by itself, sufficient to classify it as a complication.
Option A therefore assumes a complication that may not exist. Option C improperly alters provider documentation without clarification. Option D mistakes treatment for diagnosis.
A compliant query should objectively present respiratory findings, duration of ventilation, reintubation or escalation when present, and the operative/anesthesia documentation, then allow the provider to characterize the condition.
CCDS Reference Topics: Postoperative respiratory failure; complications of care; mechanical ventilation; clinical validation.
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NEW QUESTION # 32
A CDI program plans to develop a policy for addressing diagnoses that require clinical validation. According to the Guidelines for Achieving a Compliant Query Practice, which of the following should be addressed in the policy?
Answer: B
Explanation:
A compliant clinical-validation process should include a defined escalation process. The AHIMA/ACDIS query guidance specifically recommends organizational query policies that address escalation when a query remains unanswered or when documentation and clinical-validation concerns cannot be resolved through the ordinary workflow. Escalation may involve CDI or coding leadership, a physician advisor, the chief medical officer, or other designated personnel according to organizational policy.
Option A is inappropriate because simply coding every documented diagnosis without addressing significant clinical-support concerns undermines data integrity and increases denial and compliance risk. Option B is also too absolute. Coding professionals cannot independently substitute their clinical judgment for that of the responsible provider; unclear or potentially unsupported diagnoses should be addressed through an established clarification and validation process. Option D is incorrect because queries may appropriately occur concurrently or retrospectively depending on the circumstances and organizational workflow.
The goal of clinical validation is not to force removal or confirmation of a diagnosis. It is to ensure that the provider has an opportunity to clarify whether the diagnosis accurately represents the patient's clinical condition and to document supporting reasoning where appropriate.
CCDS Reference Topics: Professionalism, ethics, and compliance; clinical validation; compliant query policies; escalation procedures.
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NEW QUESTION # 33
The documentation is insufficient to determine whether a reportable diagnosis was present at the time of inpatient admission. Which POA indicator represents this situation?
Answer: B
Explanation:
POA indicator U means that the documentation is insufficient to determine whether the condition was present on admission.
This is different from Y, which indicates that the condition was present when inpatient admission occurred, and N, which indicates that the condition was not present at admission. Indicator W is used when the provider is unable to clinically determine whether the condition was present at the time of inpatient admission.
The distinction between U and W is especially important. U reflects inadequacy of the documentation, whereas W reflects a clinical determination that the timing cannot be established despite appropriate evaluation.
CDI specialists should generally attempt to resolve unclear timing when clinically feasible before a case reaches final coding. Accurate POA assignment can influence CMS Hospital-Acquired Condition payment logic and quality measurement.
CMS publishes an annual list of diagnoses exempt from POA reporting and maintains the FY 2026 POA resources separately from the HAC code lists.
POA reporting focuses on the condition's status at inpatient admission, not merely when it was first documented or when diagnostic confirmation became available.
CCDS Reference Topics: POA indicators; U versus W; HACs; admission timing; inpatient reporting.
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NEW QUESTION # 34
A patient is admitted with shortness of breath and dyspnea. Physical examination documents percussion dullness of the chest and decreased breath sounds. A chest x-ray indicates an increase in fluid with complete opacification of the hemithorax and mediastinal shift to the contralateral side. Which of the following conditions should be queried with the physician?
Answer: D
Explanation:
The findings are characteristic of a large or massive pleural effusion. Pleural fluid produces dullness to percussion and diminished breath sounds because fluid within the pleural space reduces normal transmission of respiratory sounds and replaces the normally air-filled acoustic environment.
A sufficiently large effusion can cause complete or near-complete opacification of a hemithorax on chest radiography. Importantly, a large-volume effusion exerts mass effect and can push the mediastinum away from the affected side, producing contralateral mediastinal shift. That combination strongly supports pleural effusion as the appropriate diagnostic clarification.
Pneumonia can produce focal opacity and abnormal breath sounds, but extensive consolidation often causes air bronchograms and typically does not create the same fluid-related contralateral mass effect. Atelectasis can opacify a hemithorax but usually pulls the mediastinum toward the affected side because of volume loss.
Bronchiectasis has different radiographic characteristics, including chronic bronchial dilation. Heart failure may cause pleural effusions but does not itself describe the immediate radiographic abnormality being presented.
A CDI query should seek provider confirmation rather than independently diagnose the effusion.
CCDS Reference Topics: Pleural disease; chest radiographic interpretation; pulmonary clinical indicators; diagnostic clarification.
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NEW QUESTION # 35
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