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| Section | Weight | Objectives |
|---|---|---|
| Topic 1: Communication skills | 9.17% | - CDI and coding roles and interdisciplinary collaboration - Physician education and effective communication |
| Topic 2: Official Guidelines for Coding and Reporting | 14.17% | - Principal and secondary diagnosis assignment - Coding guidelines, AHA Coding Clinic, HACs, and POA indicators |
| Topic 3: Healthcare facility CDI program analysis | 8.33% | - CDI productivity, provider response, CMI, and program metrics - Data analysis, forecasting, and performance measurement |
| Topic 4: 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 5: Healthcare regulations, reimbursement, and documentation requirements related to the IPPS | 12.5% | - CC/MCC, CMI, Medicare contractors, and compliance - IPPS, MS-DRGs, reimbursement, and medical necessity |
| Topic 6: Professionalism, ethics, and compliance | 9.17% | - Confidentiality, DRG compliance, and ethical CDI practices - Query compliance, DRG creep, and audit risks |
| Topic 7: Anatomy and physiology, pathophysiology, pharmacology, and medical terminology | 19.17% | - Anatomy, physiology, pathophysiology, pharmacology, and terminology - Clinical conditions and clinical indicators |
| Topic 8: Medical record documentation | 19.17% | - Documentation clarification and compliant physician queries - Documentation requirements and diagnosis or procedure code assignment |
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NEW QUESTION # 146
A physician documents obesity. A registered dietitian records a BMI of 38.4 kg/m². Which statement is MOST accurate?
Answer: A
NEW QUESTION # 147
When reviewing a patient's chart in the ICU, a CDI specialist determines a query needs to be placed. As the query is being written, the attending physician is leaving the patient's room after completing rounds. Which of the following is the BEST action to take?
Answer: B
Explanation:
A verbal query is the most efficient and appropriate action because the responsible physician is immediately available and the documentation gap has already been identified. CDI practice is not limited to written or electronic queries; verbal clarification is an accepted communication method when conducted compliantly.
The CDI specialist should present the relevant clinical indicators objectively and ask for clarification without directing the physician toward a preferred diagnosis. The conversation should remain clinically focused and must not mention reimbursement, MS-DRG impact, quality scoring, or other incentives.
Importantly, verbal does not mean informal or undocumented. Current query standards require organizations to maintain an auditable query process. Historically, ACDIS/AHIMA guidance has specifically required the essence of verbal queries to be memorialized, including the reason for clarification and relevant clinical indicators. The 2026 ACDIS/AHIMA Guidelines for Achieving a Compliant Query Practice supersede previous versions and remain the current foundational industry standard for query practice.
Waiting unnecessarily could delay clarification and interfere with concurrent CDI workflow. Since the physician is available, direct professional communication is preferable.
CCDS Reference Topics: Communication skills; verbal queries; concurrent CDI review; compliant query practice.
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NEW QUESTION # 148
A patient with active breast cancer is admitted solely to receive a scheduled cycle of antineoplastic chemotherapy. No complication or acute disease process is responsible for the admission. Which diagnosis is generally sequenced first?
Answer: C
Explanation:
When an inpatient encounter is solely for administration of chemotherapy, the encounter-for-chemotherapy code is generally sequenced first, followed by the code identifying the malignancy being treated.
This represents an important exception to the usual expectation that the underlying disease is the principal diagnosis. The circumstances of admission are specifically treatment administration rather than management of an acute complication of the malignancy.
If, however, the patient were admitted because of a complication-such as chemotherapy-induced neutropenic fever, dehydration, anemia, or another adverse effect-the principal-diagnosis analysis would follow the applicable guideline for that condition rather than automatically using the chemotherapy encounter code.
Similarly, if chemotherapy were administered incidentally during a hospitalization principally required for another condition, the encounter-for-chemotherapy code would not displace the actual principal diagnosis.
CDI professionals should therefore distinguish planned treatment encounters from admissions caused by complications of treatment or malignancy.
Clear documentation regarding the reason for admission, cancer site, treatment intent, metastatic disease, and complications helps support proper sequencing and accurate oncology data.
CCDS Reference Topics: Antineoplastic chemotherapy; encounter codes; neoplasm sequencing; principal diagnosis; oncology documentation.
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NEW QUESTION # 149
A patient undergoes abdominal surgery. Two days later, the physician documents "postoperative anemia." The hemoglobin decreased from 12.4 g/dL preoperatively to 8.2 g/dL, but the record does not state whether the anemia represents an expected postoperative condition, acute blood loss anemia, or a complication of surgery. What should the CDI specialist do?
Answer: C
Explanation:
The appropriate action is to query for clarification. A temporal relationship-anemia occurring after surgery- does not automatically establish that a reportable complication occurred. Likewise, a CDI specialist cannot independently translate a substantial hemoglobin decline into acute posthemorrhagic anemia without provider documentation.
The FY 2026 Official Guidelines state that complication-of-care code assignment depends on provider documentation establishing the relationship between the condition and the care or procedure unless the classification specifically instructs otherwise. They also emphasize that not every condition occurring during or following medical care is a complication.
The query could present the preoperative and postoperative hemoglobin values, estimated blood loss, transfusions, clinical monitoring, and treatment. Appropriate response options might include acute blood loss anemia, expected postoperative anemia, another diagnosis, or clinically unable to determine, depending on the record.
Option A overstates causation. Option B independently diagnoses the patient from laboratory findings. Option D is equally inappropriate because clinically significant postoperative anemia may be reportable.
CCDS Reference Topics: Complications of care; postoperative anemia; clinical indicators; cause-and-effect clarification; compliant querying.
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NEW QUESTION # 150
Which of the following is a characteristic of a reportable secondary diagnosis?
Answer: C
Explanation:
Increased nursing care is specifically included in the UHDDS/ICD-10-CM definition of a clinically significant reportable secondary diagnosis. A secondary condition is reportable when it affects patient care by requiring clinical evaluation, therapeutic treatment, diagnostic procedures, an extended length of stay, or increased nursing care and/or monitoring.
This distinction prevents conditions that merely appear in the record but have no relevance to the current encounter from automatically becoming reportable secondary diagnoses. For example, a historical diagnosis that does not influence treatment, monitoring, evaluation, or length of stay generally should not be coded simply because it appears in a problem list.
Option A is imprecise. A secondary condition may extend the hospitalization, but it does not need to be the condition that originally "required hospital stay." Option B is the opposite of the guideline criterion, which refers to extended, not decreased, length of stay. Option C is also insufficient by itself: provider documentation establishes diagnoses, but documentation alone does not necessarily make every historical or clinically irrelevant condition reportable.
CDI specialists must therefore evaluate both provider documentation and the clinical significance of secondary conditions.
CCDS Reference Topics: Reporting additional diagnoses; UHDDS; secondary diagnosis criteria; resource utilization.
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NEW QUESTION # 151
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