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| Section | Weight | Objectives |
|---|---|---|
| Impact of reportable diagnoses on quality of care | 8.33% | - Quality data from record abstraction and claims data - Hospital Inpatient Quality Reporting Program - Patient Safety Indicators - Documentation and code assignment impact on mortality index - Hospital-Acquired Condition Reduction Program - CDI impact on Hospital Value-Based Purchasing - Healthcare-associated infections and complication codes - Hospital Readmissions Reduction Program - Coded data elements affecting Patient Safety Indicators - Hospital Value-Based Purchasing - Mortality reviews and observed/expected ratios - 30-day mortality measures |
| Official Guidelines for Coding and Reporting | 14.17% | - Principal diagnosis assignment - Official Guidelines for Coding and Reporting updates - Hospital-acquired conditions - AHA Coding Clinic - Working DRG assignment for multiple diagnoses - Coding guidelines for principal diagnosis selection - Present on admission indicators - Discharge dispositions and transfers - Secondary diagnosis assignment |
| Healthcare facility CDI program analysis | 8.33% | - Provider response rates - Hospital Value-Based Purchasing measures - CDI program forecasting - Hospital-specific financial data - Tracking and trending physician, department, and hospital performance - CDI specialist productivity metrics - Patient Safety Indicators - Physician performance measurement - Severity of illness and risk of mortality - Basic computer and software application skills - High-frequency DRGs - CC/MCC capture - PEPPER data - Case mix index (CMI) - Publicly reported data |
| Anatomy and physiology, pathophysiology, pharmacology, and medical terminology | 19.17% | - Diseases and disorders of the respiratory system - Endocrine, nutritional, and metabolic diseases and disorders - Pharmaceuticals and disease processes - HIV infections - Diseases and disorders of the skin, subcutaneous tissue, and breast - Diseases and disorders of the blood and blood-forming organs and immunological disorders - Diseases and disorders of the musculoskeletal system - Alcohol/drug use and alcohol/drug-induced organic brain disorders - Diseases and disorders of the nervous system - Diagnostic tests as clinical indicators - Medications as clinical indicators - Diseases and disorders of the digestive system - Infectious and parasitic diseases - Diseases and disorders of the hepatobiliary system - Diseases and disorders of the circulatory system - Standard medical abbreviations - Diseases and disorders of the kidney and urinary tract - Clinical indicators and query opportunities by Major Diagnostic Category - Myeloproliferative diseases and disorders and poorly differentiated neoplasms - Injuries, poisonings, and toxic effects of drugs - Mental diseases and disorders |
| Professionalism, ethics, and compliance | 9.17% | - Compliance risks indicated by PEPPER - Potential DRG creep - Medical record confidentiality - DRG compliance initiatives - Leading queries - CDI department goals beyond reimbursement |
| Healthcare regulations, reimbursement, and documentation requirements related to the IPPS | 12.5% | - Complication/comorbidity (CC) - Documentation and medical necessity of setting - Medicare contractors and their impact on CDI - Medicare Severity Diagnosis Related Groups (MS-DRGs) - Major complication/comorbidity (MCC) - Principal diagnosis and medical necessity - Medical staff and clinical staff documentation responsibilities - Coding and billing practices vulnerable to denial - Documentation impact on IPPS reimbursement - Inpatient admission criteria and CMS Two-Midnight Rule - IPPS and its updates and revisions - Case mix index (CMI) |
| Medical record documentation | 19.17% | - Translating clinical indicators into compliant queries - When a physician query is warranted - Health record elements used for diagnosis and procedure code assignment - Provider role and diagnosis code assignment - Addressing diagnoses without clinical support - Documentation requiring clarification - Types of physician queries - Compliant and noncompliant queries - ACDIS/AHIMA Guidelines for Achieving a Compliant Query Practice - Clinical indicators - Situations in which queries are not appropriate - Physician query formats |
| Communication skills | 9.17% | - Roles and responsibilities of CDI specialists - Educational presentations for healthcare departments and administration - Effective and non-confrontational physician communication - Roles and responsibilities of coders working with CDI departments - Verbal versus written physician communication - Reconciling CDI working DRGs with final coded DRGs - Physician education forms and tools |
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NEW QUESTION # 87
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: A
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 # 88
A patient is admitted with a stage 2 sacral pressure ulcer. During the hospitalization, the ulcer progresses and is documented as stage 3 at the same site. How should the pressure ulcer be reported?
Answer: D
Explanation:
The FY 2026 ICD-10-CM Official Guidelines specifically address a pressure ulcer that progresses to a higher stage during an inpatient admission. Two codes are assigned: one representing the site and stage present on admission and another representing the same ulcer site at the highest stage documented during the hospitalization.
Therefore, this patient's stage 2 sacral pressure ulcer on admission and subsequent progression to stage 3 must both be represented according to the applicable coding instructions.
The distinction is important for both clinical and quality purposes because the record must accurately show what condition existed when the patient entered the hospital and how the wound subsequently evolved.
Coding only the stage 3 ulcer would lose information about its status at admission. Coding only stage 2 would fail to represent the deterioration that occurred during the stay.
Pressure-ulcer staging is also one of the circumstances in which qualified non-provider clinician documentation, such as wound-care nursing documentation, may be used to establish stage when the diagnosis itself is appropriately documented.
For CDI, accurate wound location, stage, progression, and POA documentation are essential because advanced pressure injuries may influence MS-DRG severity and hospital quality reporting.
CCDS Reference Topics: Pressure ulcers; staging; POA; wound-care documentation; Official Guidelines.
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NEW QUESTION # 89
A patient is admitted with hypertension and stage 3b chronic kidney disease. The physician does not explicitly state that the CKD is caused by hypertension. The record contains no documentation indicating that the two conditions are unrelated. Which of the following is the MOST appropriate approach when assigning the working diagnoses?
Answer: D
Explanation:
ICD-10-CM presumes a causal relationship between hypertension and chronic kidney disease when both are documented, unless the provider specifically states that the conditions are unrelated. Therefore, the working coding logic should recognize hypertensive CKD and additionally identify the patient's CKD stage.
The FY 2026 Official Guidelines direct assignment of a code from category I12, Hypertensive chronic kidney disease, when hypertension and a condition classified to N18.- are both present. An additional N18.- code is required to identify the CKD stage. In this case, the documented stage is 3b.
A provider query solely to establish the hypertension-CKD relationship is unnecessary because ICD-10-CM itself supplies the presumed relationship. However, a query could become necessary if the physician explicitly states or strongly suggests that the CKD is unrelated to hypertension or if conflicting documentation exists.
The CDI specialist must distinguish coding conventions that automatically establish certain relationships from situations in which provider linkage is mandatory. This prevents unnecessary queries and supports accurate working-DRG assignment.
CCDS Reference Topics: Hypertensive CKD; presumed causal relationships; CKD staging; coding conventions; working MS-DRG.
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NEW QUESTION # 90
A patient is admitted with chest pain and borderline elevation of troponins. The patient also reports a history of GERD. The physician documents that the chest pain is "likely GI in origin" and prescribes omeprazole.
Based on the clinical indicators, which of the following actions should the CDI specialist take?
Answer: C
Explanation:
The documentation does not clearly establish the definitive condition chiefly responsible for the inpatient admission. The patient has chest pain, borderline troponin elevation, and a history of GERD, while the physician describes the symptoms only as "likely GI in origin." The appropriate CDI action is therefore to clarify the condition responsible for the admission rather than independently select GERD or myocardial infarction.
A history of GERD does not establish that GERD caused the present chest pain. Likewise, borderline troponin elevation alone does not establish an AMI, so a query that directs the provider toward AMI would be inappropriate without stronger clinical support.
For inpatient coding, uncertain diagnoses documented at discharge using terms such as "probable,"
"suspected," or "likely" may be coded as though established. However, the phrase "GI in origin" still fails to identify a specific gastrointestinal disease responsible for the admission. The CDI specialist's purpose is to obtain clinically meaningful diagnostic clarification rather than infer a diagnosis from treatment such as omeprazole.
A compliant query should include the relevant symptoms, diagnostic findings, treatment, and supported alternatives without indicating financial consequences.
CCDS Reference Topics: Principal diagnosis clarification; ambiguous documentation; compliant querying; clinical indicators.
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NEW QUESTION # 91
Which of the following conditions demonstrates the greatest risk of mortality in a 77-year-old patient?
Answer: D
Explanation:
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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NEW QUESTION # 92
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