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| Section | Weight | Objectives |
|---|---|---|
| Medical record documentation | 19.17% | - Physician query formats - Health record elements used for diagnosis and procedure code assignment - Situations in which queries are not appropriate - Documentation requiring clarification - ACDIS/AHIMA Guidelines for Achieving a Compliant Query Practice - When a physician query is warranted - Types of physician queries - Addressing diagnoses without clinical support - Provider role and diagnosis code assignment - Clinical indicators - Translating clinical indicators into compliant queries - Compliant and noncompliant queries |
| Communication skills | 9.17% | - Effective and non-confrontational physician communication - Physician education forms and tools - Verbal versus written physician communication - Roles and responsibilities of coders working with CDI departments - Educational presentations for healthcare departments and administration - Reconciling CDI working DRGs with final coded DRGs - Roles and responsibilities of CDI specialists |
| Healthcare facility CDI program analysis | 8.33% | - Severity of illness and risk of mortality - High-frequency DRGs - Hospital Value-Based Purchasing measures - Provider response rates - Hospital-specific financial data - Publicly reported data - CC/MCC capture - Basic computer and software application skills - Patient Safety Indicators - CDI program forecasting - CDI specialist productivity metrics - Physician performance measurement - Case mix index (CMI) - PEPPER data - Tracking and trending physician, department, and hospital performance |
| Anatomy and physiology, pathophysiology, pharmacology, and medical terminology | 19.17% | - Mental diseases and disorders - Diseases and disorders of the respiratory system - Diseases and disorders of the circulatory system - Myeloproliferative diseases and disorders and poorly differentiated neoplasms - Diseases and disorders of the skin, subcutaneous tissue, and breast - Diseases and disorders of the musculoskeletal system - Alcohol/drug use and alcohol/drug-induced organic brain disorders - Diseases and disorders of the blood and blood-forming organs and immunological disorders - Standard medical abbreviations - Clinical indicators and query opportunities by Major Diagnostic Category - Diseases and disorders of the digestive system - Diagnostic tests as clinical indicators - Diseases and disorders of the hepatobiliary system - Injuries, poisonings, and toxic effects of drugs - Infectious and parasitic diseases - Diseases and disorders of the kidney and urinary tract - Diseases and disorders of the nervous system - Endocrine, nutritional, and metabolic diseases and disorders - Medications as clinical indicators - HIV infections - Pharmaceuticals and disease processes |
| Official Guidelines for Coding and Reporting | 14.17% | - Official Guidelines for Coding and Reporting updates - Working DRG assignment for multiple diagnoses - Coding guidelines for principal diagnosis selection - Present on admission indicators - Discharge dispositions and transfers - Hospital-acquired conditions - Principal diagnosis assignment - Secondary diagnosis assignment - AHA Coding Clinic |
| Professionalism, ethics, and compliance | 9.17% | - DRG compliance initiatives - CDI department goals beyond reimbursement - Medical record confidentiality - Potential DRG creep - Compliance risks indicated by PEPPER - Leading queries |
| Healthcare regulations, reimbursement, and documentation requirements related to the IPPS | 12.5% | - Medicare Severity Diagnosis Related Groups (MS-DRGs) - Documentation impact on IPPS reimbursement - Complication/comorbidity (CC) - IPPS and its updates and revisions - Major complication/comorbidity (MCC) - Medical staff and clinical staff documentation responsibilities - Medicare contractors and their impact on CDI - Principal diagnosis and medical necessity - Documentation and medical necessity of setting - Inpatient admission criteria and CMS Two-Midnight Rule - Coding and billing practices vulnerable to denial - Case mix index (CMI) |
| Impact of reportable diagnoses on quality of care | 8.33% | - Hospital Inpatient Quality Reporting Program - 30-day mortality measures - Hospital Readmissions Reduction Program - CDI impact on Hospital Value-Based Purchasing - Mortality reviews and observed/expected ratios - Hospital-Acquired Condition Reduction Program - Patient Safety Indicators - Coded data elements affecting Patient Safety Indicators - Hospital Value-Based Purchasing - Documentation and code assignment impact on mortality index - Quality data from record abstraction and claims data - Healthcare-associated infections and complication codes |
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NEW QUESTION # 35
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: C
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 # 36
A registered dietitian documents severe malnutrition based on substantial weight loss, severe muscle depletion, and prolonged inadequate energy intake. The attending physician documents only "poor oral intake." What is the BEST action for the CDI specialist?
Answer: A
Explanation:
The appropriate action is to query the provider regarding the patient's nutritional diagnosis. The dietitian's assessment supplies important clinical evidence, but the associated diagnosis of malnutrition generally must be documented by an appropriate provider before the diagnosis code is assigned.
The FY 2026 ICD-10-CM Official Guidelines permit selected elements to come from non-provider clinicians-such as BMI, pressure-ulcer stage, coma scale, NIH Stroke Scale, certain social determinants, and other specifically identified exceptions. Malnutrition diagnosis itself is not simply assigned solely from a dietitian's diagnostic statement under this general rule.
Ignoring the dietitian's findings would also be inappropriate. CDI review should integrate multidisciplinary documentation because such documentation can reveal valid clarification opportunities. Severe weight loss, reduced intake, and documented muscle depletion provide a clinical basis for a neutral query.
The query should not state that severe malnutrition "must" be documented because it is an MCC. Instead, it should present the relevant nutrition findings and allow the provider to determine the diagnosis, including severe malnutrition, another level of malnutrition, another cause, or inability to determine.
CCDS Reference Topics: Malnutrition; multidisciplinary documentation; provider diagnosis requirements; clinical indicators.
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NEW QUESTION # 37
A patient's baseline creatinine is 1.0 mg/dL. Following prolonged hypotension, creatinine rises to 3.8 mg/dL.
Urinalysis demonstrates granular casts, and the nephrologist documents "acute renal failure" but does not specify the underlying renal lesion. Which condition would be MOST appropriate to consider in a clinically supported clarification query?
Answer: C
Explanation:
The clinical pattern supports consideration of acute tubular necrosis (ATN) as a clarification opportunity.
Prolonged hypotension can cause renal ischemia severe enough to injure tubular epithelial cells. A substantial acute creatinine increase and granular or "muddy brown" casts are classic clinical findings associated with ATN.
The provider has already documented acute renal failure, so the purpose of the query would be to clarify the underlying type of acute kidney injury when clinically appropriate-not to create AKI from laboratory data alone.
Stage 5 chronic kidney disease requires evidence of chronic, persistent severe renal dysfunction and cannot be inferred from an acute creatinine rise following hypotension. Nephrotic syndrome is characterized principally by substantial proteinuria, hypoalbuminemia, edema, and other findings not described here. Pyelonephritis would ordinarily require evidence of upper urinary infection.
A CDI specialist should review the complete clinical record, including baseline renal function, hemodynamic course, nephrology notes, urinalysis, fluid management, nephrotoxic exposures, and renal replacement therapy when applicable.
The CCDS competency framework includes renal failure, laboratory interpretation, and recognition of clinically supported opportunities for diagnostic specificity.
CCDS Reference Topics: Acute kidney injury; acute tubular necrosis; renal pathophysiology; clinical indicators; diagnostic specificity.
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NEW QUESTION # 38
A hospital's query policy states that all answered queries will be retained, but all unanswered queries that might delay billing will be permanently destroyed. What is the PRIMARY compliance concern?
Answer: C
Explanation:
The principal concern is the selective destruction of unanswered queries. A compliant query-retention policy should be consistent, defensible, and auditable rather than dependent on whether the physician provided a response or whether the query affected billing.
Organizations may structure query retention differently depending on legal requirements, health-record policy, technology, and organizational governance. Queries may be part of the permanent health record or retained as another retrievable business record, depending on policy. The key point is that disposition should not be manipulated to hide unanswered or inconvenient clarification activity.
Destroying unresolved queries can impair auditability, create an appearance that the organization is selectively preserving only favorable documentation activity, and undermine the integrity of the CDI process.
The 2026 ACDIS/AHIMA guidelines are the current foundational standard for query-practice design and supersede prior versions.
A query need not automatically remain in the permanent medical record forever; retention requirements depend on applicable organizational and legal policies. What is unacceptable is an inconsistent approach designed to remove evidence based on outcome.
CCDS Reference Topics: Query retention; compliance; auditability; organizational policy; documentation integrity.
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NEW QUESTION # 39
A physician documents obesity. A registered dietitian records a BMI of 38.4 kg/m². Which statement is MOST accurate?
Answer: B
NEW QUESTION # 40
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