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| Section | Weight | Objectives |
|---|---|---|
| Communication skills | 9.17% | - Roles and responsibilities of CDI specialists - Verbal versus written physician communication - Educational presentations for healthcare departments and administration - Reconciling CDI working DRGs with final coded DRGs - Physician education forms and tools - Effective and non-confrontational physician communication - Roles and responsibilities of coders working with CDI departments |
| Healthcare facility CDI program analysis | 8.33% | - CDI program forecasting - CC/MCC capture - Provider response rates - High-frequency DRGs - Tracking and trending physician, department, and hospital performance - Hospital-specific financial data - Hospital Value-Based Purchasing measures - Publicly reported data - PEPPER data - CDI specialist productivity metrics - Severity of illness and risk of mortality - Basic computer and software application skills - Case mix index (CMI) - Patient Safety Indicators - Physician performance measurement |
| Professionalism, ethics, and compliance | 9.17% | - Leading queries - Compliance risks indicated by PEPPER - Medical record confidentiality - Potential DRG creep - CDI department goals beyond reimbursement - DRG compliance initiatives |
| Medical record documentation | 19.17% | - When a physician query is warranted - Documentation requiring clarification - Types of physician queries - Provider role and diagnosis code assignment - Situations in which queries are not appropriate - Compliant and noncompliant queries - Health record elements used for diagnosis and procedure code assignment - Addressing diagnoses without clinical support - ACDIS/AHIMA Guidelines for Achieving a Compliant Query Practice - Translating clinical indicators into compliant queries - Physician query formats - Clinical indicators |
| Official Guidelines for Coding and Reporting | 14.17% | - AHA Coding Clinic - Discharge dispositions and transfers - Hospital-acquired conditions - Present on admission indicators - Secondary diagnosis assignment - Official Guidelines for Coding and Reporting updates - Working DRG assignment for multiple diagnoses - Principal diagnosis assignment - Coding guidelines for principal diagnosis selection |
| Impact of reportable diagnoses on quality of care | 8.33% | - CDI impact on Hospital Value-Based Purchasing - Quality data from record abstraction and claims data - 30-day mortality measures - Mortality reviews and observed/expected ratios - Hospital Value-Based Purchasing - Hospital Inpatient Quality Reporting Program - Healthcare-associated infections and complication codes - Documentation and code assignment impact on mortality index - Hospital-Acquired Condition Reduction Program - Coded data elements affecting Patient Safety Indicators - Hospital Readmissions Reduction Program - Patient Safety Indicators |
| Anatomy and physiology, pathophysiology, pharmacology, and medical terminology | 19.17% | - Diseases and disorders of the hepatobiliary system - Clinical indicators and query opportunities by Major Diagnostic Category - Diseases and disorders of the skin, subcutaneous tissue, and breast - Medications as clinical indicators - Injuries, poisonings, and toxic effects of drugs - Diseases and disorders of the digestive system - Diseases and disorders of the kidney and urinary tract - Standard medical abbreviations - Endocrine, nutritional, and metabolic diseases and disorders - Alcohol/drug use and alcohol/drug-induced organic brain disorders - Pharmaceuticals and disease processes - Myeloproliferative diseases and disorders and poorly differentiated neoplasms - Infectious and parasitic diseases - Diseases and disorders of the circulatory system - Mental diseases and disorders - Diseases and disorders of the blood and blood-forming organs and immunological disorders - HIV infections - Diseases and disorders of the musculoskeletal system - Diagnostic tests as clinical indicators - Diseases and disorders of the respiratory system - Diseases and disorders of the nervous system |
| Healthcare regulations, reimbursement, and documentation requirements related to the IPPS | 12.5% | - Medicare Severity Diagnosis Related Groups (MS-DRGs) - Inpatient admission criteria and CMS Two-Midnight Rule - Documentation and medical necessity of setting - Coding and billing practices vulnerable to denial - Major complication/comorbidity (MCC) - Principal diagnosis and medical necessity - Medicare contractors and their impact on CDI - Medical staff and clinical staff documentation responsibilities - Documentation impact on IPPS reimbursement - Complication/comorbidity (CC) - IPPS and its updates and revisions - Case mix index (CMI) |
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NEW QUESTION # 29
A CDI specialist reviews a prior hospitalization and finds that the patient previously had chronic systolic heart failure. During the current admission, the provider documents only "history of CHF," although the patient remains on long-term heart-failure therapy. What is the BEST approach?
Answer: A
Explanation:
Prior-encounter information may provide valuable clinical context, but it should not automatically be imported as a current reportable diagnosis without considering whether the condition remains active and relevant to the present encounter.
Here, a prior diagnosis of chronic systolic heart failure, ongoing heart-failure therapy, and ambiguous current wording such as "history of CHF" create a reasonable opportunity to clarify the patient's current heart-failure status if that information is clinically relevant.
The CDI specialist should not independently carry forward the previous diagnosis or escalate it to acute heart failure. Conversely, rigidly ignoring reliable prior clinical information can prevent identification of legitimate documentation gaps.
The 2026 ACDIS/AHIMA query guidance specifically includes the role of prior encounters as part of its updated query-practice framework, while emphasizing compliant provider clarification and accurate representation of the current patient's clinical status.
A query should make clear which current clinical indicators support the need for clarification and should not imply that a previous diagnosis must automatically remain valid.
CCDS Reference Topics: Prior encounters; chronic conditions; heart failure; query practice; current- encounter documentation.
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NEW QUESTION # 30
A CDI specialist drafts the following query:
"Please document acute respiratory failure because the patient's oxygen saturation is 84% and this diagnosis will qualify as an MCC." What is the MOST appropriate action?
Answer: D
Explanation:
The query should be rewritten as a neutral, clinically supported clarification request. The original wording is noncompliant because it directs the physician toward a particular diagnosis and explicitly identifies its reimbursement consequence.
The current ACDIS/AHIMA 2026 Guidelines for Achieving a Compliant Query Practice, released in August
2026, supersede prior versions and emphasize that the query process exists to ensure the health record accurately reflects the patient's clinical status.
A compliant query could present relevant findings such as oxygen saturation, respiratory rate, blood-gas values, oxygen requirements, work of breathing, escalation to noninvasive or invasive ventilation, and treatment. It should then request clarification using clinically reasonable choices or another compliant format without highlighting which answer produces an MCC.
An oxygen saturation of 84% may be an important indicator, but a CDI specialist may not convert that finding independently into respiratory failure. The provider must evaluate the complete clinical picture.
Approval from a coding manager does not cure biased wording. Substituting "CC" for "MCC" likewise leaves the fundamental compliance problem intact.
CCDS Reference Topics: Query compliance; leading queries; respiratory failure; ethical CDI practice.
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NEW QUESTION # 31
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: D
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 # 32
A physician documents obesity. A registered dietitian records a BMI of 38.4 kg/mยฒ. Which statement is MOST accurate?
Answer: A
NEW QUESTION # 33
A pregnant patient is admitted at 30 weeks' gestation with acute pyelonephritis complicating pregnancy.
Which general sequencing principle applies?
Answer: B
Explanation:
ICD-10-CM Chapter 15 codes generally have sequencing priority over codes from other chapters when a condition complicates pregnancy, childbirth, or the puerperium.
Therefore, when pyelonephritis complicates pregnancy, the appropriate obstetric complication code is generally sequenced first, with additional code(s) used as instructed to identify the specific infection or organism.
This principle is important because ordinary principal-diagnosis logic can be modified by chapter-specific instructions. CDI specialists working with obstetric cases therefore must determine whether the pregnancy affects management and whether the condition is documented as complicating pregnancy.
The only major exception would be when the provider specifically determines that the pregnancy is incidental to the encounter and the applicable coding requirements for incidental pregnancy are met.
A symptom code does not generally supersede an established definitive diagnosis. Likewise, the fact that an infection could occur outside pregnancy does not negate Chapter 15 sequencing when it is complicating the pregnancy.
Correct gestational-age documentation is also important because an additional code may be required to identify the specific week of gestation.
CCDS Reference Topics: Obstetric coding; Chapter 15; sequencing priority; infection in pregnancy; principal diagnosis.
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NEW QUESTION # 34
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