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| Section | Weight | Objectives |
|---|---|---|
| Topic 1: 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 2: Healthcare Regulations, Reimbursement & Documentation Requirements – IPPS | 15% | - Medicare Severity Diagnostic Related Groups (MS-DRGs) - Documentation responsibilities of medical and clinical staff - Inpatient Prospective Payment System (IPPS) fundamentals |
| Topic 3: CDI Program Management & Professional Practice | 15% | - Provider education and training strategies - Ethics, HIPAA, and professional conduct - Program metrics, benchmarks, and performance measurement |
| Topic 4: Coding Guidelines & Official Reporting Standards | 15% | - AHIMA/ACDIS Guidelines for Compliant Query Practice - Coding integrity and compliant documentation practices - ICD-10-CM/PCS Official Guidelines for Coding and Reporting |
| Topic 5: 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 6: Clinical Documentation Review & Query Practices | 20% | - Query development, communication, and ethical standards - Concurrent and retrospective chart review methodologies - Documentation gap identification and resolution |
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86. Frage
A patient develops a surgical-site infection after abdominal surgery and is admitted with sepsis. The surgeon clearly documents "sepsis due to postoperative wound infection." Which diagnosis category is generally sequenced first?
Antwort: C
Begründung:
Sepsis resulting from a postprocedural infection follows specialized sequencing rules. The code identifying the postprocedural infection or surgical-site infection is sequenced first when applicable, followed by the code for sepsis following a procedure and any additional codes required for the infectious organism or severe sepsis.
The FY 2026 Official Guidelines specifically state that for sepsis following a postprocedural wound or surgical-site infection, the appropriate postprocedural infection code is sequenced first. An additional code for sepsis following a procedure is then assigned. If severe sepsis exists, the appropriate R65.2- code and codes for acute organ dysfunction are additionally reported.
This differs from ordinary sepsis due to a localized infection, where the systemic infection is typically sequenced before the localized infection when sepsis is the reason for admission.
The cause-and-effect relationship is also essential. A wound infection merely occurring after surgery does not automatically establish a postprocedural complication. Here, the surgeon has explicitly documented that relationship, so the necessary clinical linkage is present.
CCDS Reference Topics: Postprocedural infection; sepsis; surgical-site infection; complication coding; sequencing.
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87. Frage
A physician is completing rounds when a CDI specialist identifies conflicting documentation that can be clarified immediately. Which approach is MOST appropriate?
Antwort: A
Begründung:
Direct verbal communication can be an effective and appropriate CDI technique, particularly when the responsible physician is available and the issue can be clarified efficiently. The interaction must remain professional, clinically focused, and compliant with the organization's process for documenting or retaining verbal queries.
ACDIS specifically identifies collaboration with providers, verbal discussion, written queries, and resolution of missing, unclear, or conflicting documentation as core inpatient CDI responsibilities. The CCDS blueprint also tests situations in which personal or verbal communication may be preferable to written communication.
Option C is inappropriate because the CDI specialist should not direct the physician toward a diagnosis based on MS-DRG impact. The discussion should present the clinical issue neutrally and allow the physician to exercise independent clinical judgment.
There is also no rule requiring all queries to be electronic. Query format and retention should follow compliant organizational policies and current ACDIS/AHIMA standards. Waiting until final billing can unnecessarily delay resolution and undermine the advantages of concurrent CDI review.
Effective CDI communication balances clinical precision, efficiency, collegiality, and auditability.
CCDS Reference Topics: Verbal queries; physician communication; concurrent CDI; nonleading clarification; query documentation.
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88. Frage
A patient is admitted with shortness of breath and dyspnea. Physical examination documents percussion dullness of the chest and decreased breath sounds. A chest x-ray indicates an increase in fluid with complete opacification of the hemithorax and mediastinal shift to the contralateral side. Which of the following conditions should be queried with the physician?
Antwort: B
Begründung:
The findings are characteristic of a large or massive pleural effusion. Pleural fluid produces dullness to percussion and diminished breath sounds because fluid within the pleural space reduces normal transmission of respiratory sounds and replaces the normally air-filled acoustic environment.
A sufficiently large effusion can cause complete or near-complete opacification of a hemithorax on chest radiography. Importantly, a large-volume effusion exerts mass effect and can push the mediastinum away from the affected side, producing contralateral mediastinal shift. That combination strongly supports pleural effusion as the appropriate diagnostic clarification.
Pneumonia can produce focal opacity and abnormal breath sounds, but extensive consolidation often causes air bronchograms and typically does not create the same fluid-related contralateral mass effect. Atelectasis can opacify a hemithorax but usually pulls the mediastinum toward the affected side because of volume loss.
Bronchiectasis has different radiographic characteristics, including chronic bronchial dilation. Heart failure may cause pleural effusions but does not itself describe the immediate radiographic abnormality being presented.
A CDI query should seek provider confirmation rather than independently diagnose the effusion.
CCDS Reference Topics: Pleural disease; chest radiographic interpretation; pulmonary clinical indicators; diagnostic clarification.
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89. Frage
Which of the following conditions demonstrates the greatest risk of mortality in a 77-year-old patient?
Antwort: D
Begründung:
Among the choices presented, sepsis associated with a urinary tract infection represents the strongest overall mortality-risk condition. Sepsis is a systemic, potentially life-threatening response to infection and is associated with substantially greater mortality risk than an uncomplicated localized infection, particularly in an elderly patient.
Risk of mortality in CDI is not determined merely by whether a diagnosis is a CC or MCC. Risk-adjustment systems evaluate the complete clinical profile, including principal diagnosis, secondary diagnoses, age, organ dysfunction, severity interactions, and other patient characteristics. Thus, reimbursement severity and predicted mortality are related concepts but are not interchangeable.
The history of mastectomy ten years earlier does not itself materially increase the current acute severity unless active malignancy or another relevant condition is present. The principal acute concern in option D is sepsis.
COPD with respiratory failure and NSTEMI with acute systolic heart failure are also high-risk presentations and require complete documentation; however, the question's intended risk-adjustment comparison identifies the septic presentation as carrying the greatest mortality concern.
If acute organ dysfunction were linked to sepsis, documentation of severe sepsis would further increase the represented clinical severity.
CCDS Reference Topics: Risk of mortality; severity adjustment; sepsis; quality reporting; distinction between MS-DRG severity and ROM.
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90. Frage
A patient is admitted with sepsis due to osteomyelitis and evidence of organ failure. Which of the following is the correct principal diagnosis?
Antwort: D
Begründung:
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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91. Frage
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