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| Section | Weight | Objectives |
|---|---|---|
| Topic 1: CDI Program Management & Professional Practice | 15% | - Ethics, HIPAA, and professional conduct - Provider education and training strategies - Program metrics, benchmarks, and performance measurement |
| Topic 2: Clinical Knowledge & Disease Processes Application | 20% | - Disease processes across body systems applied to chart review - Medical terminology, anatomy, physiology, pathophysiology - Clinical indicators, lab results, medications, diagnostic findings |
| Topic 3: Quality, Risk Adjustment & Health Initiatives | 15% | - Risk adjustment models and documentation impact - Severity of Illness (SOI) / Risk of Mortality (ROM) - Quality reporting, public reporting, and compliance programs |
| Topic 4: Clinical Documentation Review & Query Practices | 20% | - Documentation gap identification and resolution - Query development, communication, and ethical standards - Concurrent and retrospective chart review methodologies |
| Topic 5: Healthcare Regulations, Reimbursement & Documentation Requirements – IPPS | 15% | - Documentation responsibilities of medical and clinical staff - Inpatient Prospective Payment System (IPPS) fundamentals - Medicare Severity Diagnostic Related Groups (MS-DRGs) |
| Topic 6: Coding Guidelines & Official Reporting Standards | 15% | - ICD-10-CM/PCS Official Guidelines for Coding and Reporting - Coding integrity and compliant documentation practices - AHIMA/ACDIS Guidelines for Compliant Query Practice |
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NEW QUESTION # 68
The progress note on hospital day 2 of a patient's admission states that the patient got up from the bed to go to the bathroom just after housekeeping had mopped the floor. The patient slipped and fell onto the floor, sustaining a broken wrist. The diagnosis of a fractured wrist will:
Answer: B
Explanation:
The fracture occurred after inpatient admission as the result of a hospital fall, placing it within CMS's Hospital-Acquired Condition category for Falls and Trauma when the applicable fracture code is included in the HAC code list. CMS's FY 2026 MS-DRG Definitions Manual continues to identify qualifying fracture codes within HAC 05.
The fracture must still be coded; therefore, option D is incorrect. Because it clearly developed after admission, it would not appropriately receive POA indicator "U," which indicates insufficient documentation to determine whether the condition was present on admission.
For qualifying HAC diagnoses that are not POA, CMS payment logic prevents the hospital from receiving the higher MS-DRG payment that would otherwise result solely from the condition's CC/MCC status. Thus, option B expresses the intended payment effect.
This distinction is central to CDI practice: a hospital-acquired diagnosis does not disappear from the record or coding. It remains reportable for clinical and quality purposes, but certain qualifying HACs are treated differently in MS-DRG payment calculations.
CCDS Reference Topics: HACs; POA indicators; Falls and Trauma; MS-DRG payment adjustment.
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NEW QUESTION # 69
A hospital had 1,000 inpatient discharges during a reporting period. The sum of the MS-DRG relative weights for those discharges was 1,750. What is the hospital's case mix index (CMI)?
Answer: B
Explanation:
Case mix index is calculated by dividing the total MS-DRG relative weights by the number of discharges:
1,750 ÷ 1,000 = 1.75
Therefore, the hospital's CMI is 1.75.
CMI is an aggregate measure representing the average relative resource intensity of the hospital's inpatient population under the MS-DRG system. A higher CMI generally indicates that the hospital treated cases assigned to DRGs with higher average relative weights.
However, CMI should never be interpreted as a pure measure of clinical quality. It can be affected by patient population, service-line composition, surgical volume, transplant activity, documentation completeness, coding accuracy, changes in grouper methodology, and other factors.
CMS specifically publishes hospital CMI data and uses MS-DRG relative weights in the IPPS payment methodology. CMS also maintains FY 2026 case-mix and relative-weight files as part of the final-rule data package.
For CDI program analysis, unexplained CMI changes should trigger investigation rather than an automatic assumption of poor documentation. Service-line and diagnosis-level analysis usually provides a more meaningful interpretation.
CCDS Reference Topics: Case mix index; relative weights; CDI analytics; MS-DRGs; program performance.
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NEW QUESTION # 70
A patient with an indwelling urinary catheter develops fever, pyuria, and a positive urine culture during hospitalization. The physician documents "UTI" but does not state whether the infection is related to the catheter. What should the CDI specialist do?
Answer: A
Explanation:
The CDI specialist should query the provider regarding the cause-and-effect relationship between the urinary catheter and the infection. The simultaneous presence of a catheter and UTI does not, by itself, establish a device-related complication for coding.
A positive culture, pyuria, and fever may support infection, but attribution to an indwelling catheter requires appropriate provider documentation when the classification does not independently establish the relationship.
The query should present relevant facts neutrally: catheter placement and duration, fever, urinary symptoms when present, urinalysis, culture findings, antibiotic treatment, and existing UTI documentation. Possible responses should allow the physician to identify catheter-associated UTI, UTI unrelated to the catheter, another diagnosis, or inability to determine.
Option A improperly infers causation. Option C goes too far in the opposite direction; although asymptomatic bacteriuria is common in catheterized patients, the provider has documented UTI and the patient has clinical findings that may support infection. Option D similarly equates a test result with a complication diagnosis.
This is a classic CCDS cause-and-effect clarification issue and demonstrates why device-related complications require careful documentation.
CCDS Reference Topics: CAUTI; device-related complications; cause-and-effect queries; clinical indicators; quality reporting.
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NEW QUESTION # 71
A patient is admitted with sepsis due to osteomyelitis and evidence of organ failure. Which of the following is the correct principal diagnosis?
Answer: C
Explanation:
The underlying systemic infection/sepsis code is sequenced as the principal diagnosis when sepsis or severe sepsis is present on admission and is the condition chiefly responsible for admission. Therefore, sepsis is the correct selection from the available choices.
The presence of organ failure means the patient may also meet the documentation requirements for severe sepsis when the acute organ dysfunction is explicitly associated with the sepsis. However, the severe-sepsis code from subcategory R65.2- cannot be assigned as the principal diagnosis. The FY 2026 ICD-10-CM Official Guidelines require the underlying systemic infection first, followed by R65.2- and codes for the associated acute organ dysfunction.
Osteomyelitis represents the localized infection source, but when the reason for admission is sepsis associated with that localized infection, the systemic infection is sequenced first under the sepsis guidelines.
"Septicemia" should not be substituted for provider-documented sepsis.
The CDI specialist should also verify that the provider has clearly linked the organ failure to sepsis before severe-sepsis coding is applied.
CCDS Reference Topics: Sepsis sequencing; severe sepsis; principal diagnosis; localized infection.
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NEW QUESTION # 72
A patient has chronic gastroesophageal reflux disease listed in the past medical history. During the current hospitalization for bacterial pneumonia, GERD receives no clinical evaluation, treatment, diagnostic testing, increased nursing monitoring, or effect on length of stay. Which statement is MOST accurate?
Answer: D
Explanation:
A condition documented in the medical record does not automatically qualify as a reportable secondary diagnosis. For inpatient coding, additional diagnoses generally must be clinically significant during the current hospitalization. Qualifying significance includes clinical evaluation, therapeutic treatment, diagnostic procedures, an extended length of stay, or increased nursing care and/or monitoring.
Here, GERD is merely part of the patient's historical medical background and does not affect current management. Therefore, it generally should not be reported as an additional diagnosis solely because it appears in the past medical history.
Whether a diagnosis is classified as a CC or MCC is a separate issue. A condition must first satisfy applicable reporting requirements before its MS-DRG severity classification matters. CDI specialists should never encourage coding of clinically irrelevant historical conditions merely because they could affect reimbursement.
This principle protects the clinical integrity of coded data and prevents inappropriate inflation of disease burden. CDI review should focus on conditions that meaningfully describe the patient's current hospitalization, treatment requirements, clinical risk, and resource consumption.
CCDS Reference Topics: Reporting additional diagnoses; secondary-diagnosis criteria; medical-record review; resource utilization; coding compliance.
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NEW QUESTION # 73
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