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| Section | Weight | Objectives |
|---|---|---|
| Topic 1: Medical record documentation | 19.17% | - Documentation clarification and compliant physician queries - Documentation requirements and diagnosis or procedure code assignment |
| Topic 2: 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 |
| Topic 3: Official Guidelines for Coding and Reporting | 14.17% | - Principal and secondary diagnosis assignment - Coding guidelines, AHA Coding Clinic, HACs, and POA indicators |
| Topic 4: Healthcare facility CDI program analysis | 8.33% | - CDI productivity, provider response, CMI, and program metrics - Data analysis, forecasting, and performance measurement |
| Topic 5: Anatomy and physiology, pathophysiology, pharmacology, and medical terminology | 19.17% | - Anatomy, physiology, pathophysiology, pharmacology, and terminology - Clinical conditions and clinical indicators |
| Topic 6: Communication skills | 9.17% | - Physician education and effective communication - CDI and coding roles and interdisciplinary collaboration |
| Topic 7: Healthcare regulations, reimbursement, and documentation requirements related to the IPPS | 12.5% | - IPPS, MS-DRGs, reimbursement, and medical necessity - CC/MCC, CMI, Medicare contractors, and compliance |
| Topic 8: Professionalism, ethics, and compliance | 9.17% | - Confidentiality, DRG compliance, and ethical CDI practices - Query compliance, DRG creep, and audit risks |
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117. Frage
A patient is admitted with hypertension and acute systolic heart failure. The provider does not explicitly link the two conditions and does not state that they are unrelated. Which coding principle applies?
Antwort: B
Begründung:
ICD-10-CM presumes a causal relationship between hypertension and qualifying heart disease, including heart failure, because the conditions are linked under "hypertension, with" in the Alphabetic Index. The presumed relationship applies unless the provider clearly documents that the heart disease is unrelated to hypertension.
Accordingly, hypertensive heart disease is coded using the appropriate I11.- category, with an additional I50.- code identifying the specific type and acuity of heart failure.
This convention differs from conditions for which ICD-10-CM does not provide a presumed causal link. In those circumstances, provider documentation must explicitly establish the relationship.
The CDI specialist therefore should not routinely query merely to obtain wording such as "hypertensive heart failure" when both hypertension and a qualifying heart-failure diagnosis are already documented and no statement says they are unrelated.
However, CDI may still need clarification when heart-failure type or acuity is incomplete, documentation is contradictory, or the physician expressly disputes a hypertensive relationship.
Recognizing these classification-based presumptions reduces unnecessary queries and supports accurate working-code and MS-DRG assignment.
CCDS Reference Topics: Hypertensive heart disease; heart failure; presumed relationships; coding conventions; query necessity.
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118. Frage
A patient with active breast cancer is admitted solely to receive a scheduled cycle of antineoplastic chemotherapy. No complication or acute disease process is responsible for the admission. Which diagnosis is generally sequenced first?
Antwort: B
Begründung:
When an inpatient encounter is solely for administration of chemotherapy, the encounter-for-chemotherapy code is generally sequenced first, followed by the code identifying the malignancy being treated.
This represents an important exception to the usual expectation that the underlying disease is the principal diagnosis. The circumstances of admission are specifically treatment administration rather than management of an acute complication of the malignancy.
If, however, the patient were admitted because of a complication-such as chemotherapy-induced neutropenic fever, dehydration, anemia, or another adverse effect-the principal-diagnosis analysis would follow the applicable guideline for that condition rather than automatically using the chemotherapy encounter code.
Similarly, if chemotherapy were administered incidentally during a hospitalization principally required for another condition, the encounter-for-chemotherapy code would not displace the actual principal diagnosis.
CDI professionals should therefore distinguish planned treatment encounters from admissions caused by complications of treatment or malignancy.
Clear documentation regarding the reason for admission, cancer site, treatment intent, metastatic disease, and complications helps support proper sequencing and accurate oncology data.
CCDS Reference Topics: Antineoplastic chemotherapy; encounter codes; neoplasm sequencing; principal diagnosis; oncology documentation.
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119. Frage
An MS-DRG family is divided into three severity levels: with MCC, with CC, and without CC/MCC.
Assuming all other grouper conditions are identical, which secondary diagnosis category generally results in the highest severity-level assignment?
Antwort: B
Begründung:
An MCC-major complication or comorbidity-represents the highest secondary-diagnosis severity category within the standard three-tier MS-DRG hierarchy. CMS describes MCCs as diagnoses with the highest level of severity affecting hospital resource use, CCs as conditions with a moderate level, and non-CC diagnoses as the lowest severity level.
When an MS-DRG family is divided into "with MCC," "with CC," and "without CC/MCC," the presence of a qualifying MCC generally moves the case into the highest severity subdivision, assuming no exclusion or other grouper rule prevents that effect.
This does not mean every MCC always increases payment. Some secondary diagnoses are excluded as MCCs or CCs in particular circumstances because of principal-diagnosis exclusions or DRG-specific logic. CMS's FY 2026 Definitions Manual specifically contains exclusion lists and severity logic for such situations.
CDI specialists should understand MCC/CC logic to interpret working DRGs, but query activity must be driven by clinical accuracy rather than the financial value of a severity level.
CCDS Reference Topics: MS-DRGs; MCC; CC; severity subdivisions; resource utilization; reimbursement compliance.
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120. Frage
After a month of intermittent antibiotic use, the patient is admitted. An infectious-control physician documents a diagnosis of Clostridium difficile in the inpatient medical record. Which domain of the MOST current Hospital Value-Based Purchasing program would this diagnosis impact?
Antwort: B
Begründung:
The relevant Hospital Value-Based Purchasing domain is the Safety domain, corresponding most closely to option D. CMS's FY 2026 Hospital VBP program maintains a Safety domain that includes healthcare- associated infection performance measures, including C. difficile infection. CMS's current VBP Safety dataset specifically identifies C. difficile among its healthcare-associated infection measures.
It is important to distinguish the domain from an individual measure. "Hospital-acquired infection" describes the type of quality measure, but the formal broader scoring domain is Safety. PSI 90 is also associated with patient safety measurement, but it is not the name of the overall VBP domain.
From a CDI standpoint, documentation accuracy matters because coded and quality-reporting data can influence organizational performance assessment. However, documentation of C. difficile alone does not automatically establish that an infection qualifies as a hospital-onset event for every quality program. Timing and the applicable measure specifications determine whether an individual episode enters a particular healthcare-associated infection metric.
Therefore, CDI professionals should accurately capture the infection and its clinical circumstances without attempting to classify an event as hospital acquired solely to influence quality scores.
CCDS Reference Topics: Hospital VBP; Safety domain; healthcare-associated infections; C. difficile; quality reporting.
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121. Frage
A CDI specialist submits a neutral query regarding possible acute blood loss anemia. The physician answers
"clinically unable to determine." The CDI specialist believes documenting the diagnosis would increase reimbursement substantially. What is the MOST appropriate next action?
Antwort: C
Begründung:
The provider's response should be respected unless new information or a genuine unresolved documentation issue creates a legitimate reason for additional clarification.
"Clinically unable to determine" is an acceptable professional conclusion when the available evidence does not permit the provider to confidently establish a diagnosis. A CDI specialist must not continue sending essentially the same query simply because a different response would produce more favorable reimbursement.
Likewise, CDI cannot alter the provider's response or instruct coding personnel to assign a diagnosis that the provider declined to establish.
The 2026 ACDIS/AHIMA Guidelines for Achieving a Compliant Query Practice supersede all previous versions and serve as the current foundational resource for query processes. The query process is intended to improve the accuracy, completeness, and integrity of documentation-not to secure a predetermined financial result.
A legitimate follow-up could occur if new laboratory values, operative findings, transfusion information, pathology, or other material information emerges after the original response and creates a materially different clarification question.
Professional CDI practice requires balancing clinical advocacy with provider autonomy, ethical conduct, and regulatory compliance.
CCDS Reference Topics: Provider query responses; ethical CDI practice; repeated queries; provider independence; compliance.
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122. Frage
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