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| Section | Weight | Objectives |
|---|---|---|
| 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 |
| Communication skills | 9.17% | - Physician education and effective communication - CDI and coding roles and interdisciplinary collaboration |
| 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 |
| Professionalism, ethics, and compliance | 9.17% | - Query compliance, DRG creep, and audit risks - Confidentiality, DRG compliance, and ethical CDI practices |
| Anatomy and physiology, pathophysiology, pharmacology, and medical terminology | 19.17% | - Anatomy, physiology, pathophysiology, pharmacology, and terminology - Clinical conditions and clinical indicators |
| Healthcare facility CDI program analysis | 8.33% | - CDI productivity, provider response, CMI, and program metrics - Data analysis, forecasting, and performance measurement |
| Medical record documentation | 19.17% | - Documentation requirements and diagnosis or procedure code assignment - Documentation clarification and compliant physician queries |
| Official Guidelines for Coding and Reporting | 14.17% | - Coding guidelines, AHA Coding Clinic, HACs, and POA indicators - Principal and secondary diagnosis assignment |
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NEW QUESTION # 101
Which of the following diagnoses is classified as a major complication/comorbidity (MCC) under the FY
2026 MS-DRG system?
Answer: A
Explanation:
Severe protein-calorie malnutrition is the correct answer. This question is adapted from an official CCDS sample question published by ACDIS.
Under the FY 2026 MS-DRG Definitions Manual, E43, unspecified severe protein-calorie malnutrition, is classified as an MCC. In contrast, moderate and mild protein-calorie malnutrition codes are classified as CCs rather than MCCs.
An MCC can materially affect MS-DRG assignment when the applicable DRG family differentiates cases by MCC status and when no exclusion or other grouper rule prevents the effect. However, the financial effect is never sufficient justification for a query. Documentation must be clinically supported and reflect the patient's actual condition.
A dietitian may document detailed nutrition findings and malnutrition criteria, but the reportable diagnosis ordinarily requires documentation by the provider responsible for establishing diagnoses. Therefore, when strong nutritional indicators exist but the provider has not documented malnutrition, a compliant query may be appropriate.
For CCDS preparation, candidates should understand both the clinical characteristics of malnutrition and its coding/reimbursement classification.
CCDS Reference Topics: MCCs; malnutrition; MS-DRG methodology; documentation requirements; IPPS.
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NEW QUESTION # 102
A physician documents obesity. A registered dietitian records a BMI of 38.4 kg/m². Which statement is MOST accurate?
Answer: C
Explanation:
BMI is one of the recognized ICD-10-CM non-provider documentation exceptions. A qualified clinician such as a registered dietitian may document the BMI value, while the associated diagnosis-such as overweight or obesity-must be appropriately documented by the responsible provider.
Therefore, the coder may use the documented BMI of 38.4 in conjunction with the provider's obesity diagnosis when reporting requirements are otherwise satisfied.
The BMI itself does not permit the coder or CDI specialist to independently diagnose obesity or determine obesity type. Clinical diagnosis remains the provider's responsibility.
This distinction prevents unnecessary physician queries merely to reproduce objective measurements that have already been reliably documented by another qualified clinician.
Comparable non-provider documentation exceptions include pressure-ulcer stage and certain standardized scales or clinical details under applicable ICD-10-CM guidance.
CDI specialists should know these exceptions because unnecessary queries increase provider burden and can delay coding without improving data quality. Conversely, they should not extend the exception beyond what ICD-10-CM permits.
CCDS Reference Topics: BMI; obesity; non-provider documentation; dietitian documentation; coding exceptions.
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NEW QUESTION # 103
A patient is admitted with pneumonia. On hospital day 3, the patient deteriorates and the physician documents that sepsis developed after admission as a consequence of the pneumonia. Which diagnosis is generally sequenced first?
Answer: A
Explanation:
When a patient is admitted with a localized infection and sepsis develops after admission, the localized infection is generally sequenced as the principal diagnosis, followed by the appropriate sepsis code.
The FY 2026 ICD-10-CM Official Guidelines explicitly distinguish this circumstance from cases in which both the localized infection and sepsis are present on admission. When sepsis develops only after admission, the localized infection responsible for the original hospitalization remains principal.
Therefore, pneumonia is sequenced first in this scenario.
If the patient subsequently develops acute organ dysfunction related to sepsis and the provider documents severe sepsis, additional severe-sepsis and organ-dysfunction codes are assigned as appropriate. The severe- sepsis code cannot itself serve as principal diagnosis.
This question demonstrates why CDI specialists must clarify timing. Simply seeing both "pneumonia" and
"sepsis" in a discharge summary is insufficient to determine correct sequencing when the onset relationship is unclear.
The POA status of sepsis also becomes relevant because documentation indicates that it developed after inpatient admission.
CCDS Reference Topics: Sepsis; pneumonia; sequencing; timing; POA; principal diagnosis.
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NEW QUESTION # 104
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: D
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 # 105
A patient develops chest pain and elevated troponins while receiving care in the emergency department. The physician diagnoses an NSTEMI. Several hours later, an inpatient admission order is written. How should the NSTEMI generally be considered for POA purposes?
Answer: A
Explanation:
For POA reporting, "present on admission" refers to a condition present at the time the order for inpatient admission occurs. Conditions that develop during an outpatient encounter-including emergency-department, observation, or outpatient surgery care-before the inpatient admission order are generally considered POA when they are present at that inpatient admission point.
Therefore, the NSTEMI in this scenario is considered present on admission even though it developed after the patient physically arrived at the hospital.
This distinction is essential because hospital arrival and inpatient admission are not synonymous for POA purposes. A patient may spend hours in the ED or observation status before an inpatient order is entered.
The POA indicator applies to applicable principal and secondary diagnoses and is important to CMS's HAC payment provisions as well as quality analysis. A condition does not become hospital acquired merely because it arose somewhere on hospital premises before inpatient status began.
CDI specialists should clarify timing when the record does not establish whether a diagnosis existed before or after the inpatient admission order rather than relying solely on note timestamps or physical location.
The FY 2026 ICD-10-CM Official Guidelines contain the governing POA definitions and reporting rules.
CCDS Reference Topics: POA; emergency department; observation; timing of diagnosis; HAC payment logic.
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NEW QUESTION # 106
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