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| Section | Weight | Objectives |
|---|---|---|
| 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 |
| Anatomy and physiology, pathophysiology, pharmacology, and medical terminology | 19.17% | - Clinical conditions and clinical indicators - Anatomy, physiology, pathophysiology, pharmacology, and terminology |
| Communication skills | 9.17% | - Physician education and effective communication - CDI and coding roles and interdisciplinary collaboration |
| Medical record documentation | 19.17% | - Documentation requirements and diagnosis or procedure code assignment - Documentation clarification and compliant physician queries |
| Official Guidelines for Coding and Reporting | 14.17% | - Principal and secondary diagnosis assignment - Coding guidelines, AHA Coding Clinic, HACs, and POA indicators |
| Healthcare facility CDI program analysis | 8.33% | - Data analysis, forecasting, and performance measurement - CDI productivity, provider response, CMI, and program metrics |
| Professionalism, ethics, and compliance | 9.17% | - Query compliance, DRG creep, and audit risks - Confidentiality, DRG compliance, and ethical CDI practices |
| 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 |
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NEW QUESTION # 109
A CDI specialist reviews the MS-DRG mismatch report and notes a difference in a case. The coder noted that a current Coding Clinic affects the final coding of the record, which changed the MS-DRG assignment. To BEST understand this discrepancy, the specialist should FIRST:
Answer: A
Explanation:
The CDI specialist should first review the final coded record together with the Coding Clinic guidance identified by the coder. This provides an objective basis for understanding why the final MS-DRG differs from the CDI working DRG.
A mismatch does not automatically indicate that either CDI or coding made an error. Working DRGs are provisional and may change after complete review of discharge documentation, operative reports, pathology, final diagnostic information, coding conventions, official guidelines, or authoritative Coding Clinic advice.
Reviewing the applicable guidance before contacting the coder promotes an informed and efficient reconciliation process. Once the specialist understands the coding rule, discussion with the coder may still be useful if ambiguity remains. Immediately escalating to the coding manager is unnecessary unless the issue cannot be resolved through normal collaboration. Forwarding the record without investigating the mismatch would defeat the purpose of a reconciliation process and could allow recurring education opportunities to remain unidentified.
Mismatch analysis is a valuable CDI quality metric because it can identify documentation gaps, coding- knowledge issues, changes in authoritative guidance, and opportunities to improve CDI/coding alignment.
CCDS Reference Topics: MS-DRG reconciliation; CDI/coder collaboration; Coding Clinic application; CDI program analysis.
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NEW QUESTION # 110
A patient is admitted with alcohol intoxication. The H & P notes increased tolerance related to alcohol consumption, desire to drink despite impaired liver functions, and unsuccessful attempts to stop drinking.
Identify the query opportunity related to alcohol consumption.
Answer: A
Explanation:
The documented behavioral characteristics most strongly support clarification of alcohol dependence. The record describes increased tolerance, continued alcohol use despite recognized medical harm, and unsuccessful efforts to stop drinking. These features reflect a persistent maladaptive pattern with physiologic and behavioral characteristics associated with dependence/alcohol use disorder.
Alcohol intoxication identifies the acute effect of recent consumption but does not describe the patient's underlying pattern of alcohol use. Therefore, the CDI opportunity is to clarify whether a chronic alcohol- related disorder such as dependence is present when clinically supported.
Withdrawal is not established merely because a dependent patient is hospitalized. Withdrawal requires symptoms occurring after reduction or cessation of alcohol exposure, potentially including tremor, autonomic hyperactivity, nausea, anxiety, seizures, hallucinations, or agitation. Delirium tremens represents a severe alcohol-withdrawal syndrome involving delirium and marked autonomic disturbance and is not supported by the scenario.
"Abuse" is less consistent with the pronounced dependence-type behaviors provided. The CDI specialist should nevertheless frame the query neutrally and allow the physician to identify dependence, abuse, another alcohol-related condition, or inability to determine.
CCDS Reference Topics: Substance-related disorders; alcohol dependence; intoxication versus withdrawal; clinical indicators.
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NEW QUESTION # 111
A patient is admitted with TIA, right-sided weakness, and slurred speech. The physician's physical examination notes that the patient's right-sided weakness continues, but the slurred speech has resolved. A CT scan of the brain reveals a new hypodense area. The most specific diagnosis to query is acute:
Answer: B
Explanation:
The most clinically supported clarification is acute cerebral infarction. A transient ischemic attack is characterized by transient neurologic dysfunction without acute infarction. In this scenario, the patient's slurred speech has resolved, but the right-sided weakness persists, and CT demonstrates a new hypodense cerebral area. Together, those findings raise substantial concern for an established ischemic infarction rather than a completely transient event.
The CDI specialist should not independently convert the diagnosis of TIA to cerebral infarction. Instead, the persistent focal deficit and imaging findings establish an appropriate clinical basis for a provider query asking whether the final diagnosis is acute cerebral infarction, TIA, another neurologic condition, or clinically undetermined.
Acute encephalopathy generally produces global cerebral dysfunction rather than the focal unilateral weakness described here. Transient global amnesia predominantly affects memory formation and would not explain persistent unilateral motor deficits. Transient cerebral ischemia/TIA becomes less consistent once objective evidence of acute infarction and persistent neurologic impairment is present.
Accurate clarification is important because cerebral infarction and TIA differ substantially in coding, severity representation, quality reporting, and secondary-prevention planning.
CCDS Reference Topics: Neurologic clinical indicators; cerebral infarction versus TIA; diagnostic clarification; medical record specificity.
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NEW QUESTION # 112
Two diagnoses both meet the definition of principal diagnosis and either could appropriately be sequenced first under the circumstances of admission. No specific sequencing instruction directs otherwise. Which rule applies?
Answer: B
Explanation:
When two diagnoses equally meet the definition of principal diagnosis, either condition may be sequenced first when the circumstances of admission, diagnostic workup, and treatment equally support both and no specific coding guideline, tabular instruction, or other sequencing rule directs otherwise.
The principal diagnosis cannot be selected based on which option generates higher payment. Financial outcome is not a legitimate sequencing criterion.
Likewise, chronological age of the diagnosis does not determine principal-diagnosis status. The principal diagnosis is established after study as the condition chiefly responsible for occasioning the admission.
A CDI query may be appropriate when the documentation does not actually establish whether both diagnoses equally occasioned the admission. However, querying simply because one sequencing choice would produce a more favorable MS-DRG is inappropriate.
This scenario tests the distinction between valid coding flexibility and improper reimbursement-driven documentation practices. CDI professionals must understand coding conventions well enough to avoid unnecessary queries while recognizing genuine ambiguity that requires provider clarification.
The FY 2026 MS-DRG grouper and Definitions Manual published by CMS provide the applicable grouper logic for the current fiscal year.
CCDS Reference Topics: Principal diagnosis; equally qualifying diagnoses; sequencing; ethical reimbursement practice.
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NEW QUESTION # 113
A patient with dysphagia after a recent stroke develops fever, hypoxia, and a right lower-lobe infiltrate. The physician documents "pneumonia." Speech therapy documents repeated aspiration with oral intake. What is the MOST appropriate CDI action?
Answer: A
Explanation:
The record presents a legitimate opportunity to clarify the type or etiology of pneumonia, particularly whether aspiration contributed to the pulmonary infection. Dysphagia following stroke, documented aspiration during oral intake, fever, hypoxia, and a dependent-lobe infiltrate form a clinically relevant pattern.
However, the CDI specialist cannot independently convert unspecified pneumonia into aspiration pneumonia.
Likewise, the speech-language pathologist can provide valuable clinical evidence regarding swallowing dysfunction and aspiration risk, but that documentation does not independently establish the medical diagnosis of aspiration pneumonia for coding purposes.
A compliant query should objectively present the pertinent indicators and allow the provider to identify aspiration pneumonia, another pneumonia type, pneumonitis, another condition, or inability to determine.
Automatically assigning both bacterial and aspiration pneumonia would also be inappropriate because neither bacterial etiology nor a separate second pneumonia diagnosis has been established.
The current ACDIS/AHIMA guidance emphasizes that queries should arise from the clinical record and preserve the provider's independent judgment rather than directing a preferred diagnosis.
CCDS Reference Topics: Pneumonia specificity; aspiration; dysphagia; interdisciplinary documentation; compliant query development.
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NEW QUESTION # 114
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