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| Section | Weight | Objectives |
|---|---|---|
| Professionalism, ethics, and compliance | 9.17% | - Potential DRG creep - Medical record confidentiality - Compliance risks indicated by PEPPER - CDI department goals beyond reimbursement - Leading queries - DRG compliance initiatives |
| Impact of reportable diagnoses on quality of care | 8.33% | - Hospital-Acquired Condition Reduction Program - Hospital Value-Based Purchasing - Hospital Inpatient Quality Reporting Program - 30-day mortality measures - Documentation and code assignment impact on mortality index - Mortality reviews and observed/expected ratios - Hospital Readmissions Reduction Program - Quality data from record abstraction and claims data - CDI impact on Hospital Value-Based Purchasing - Healthcare-associated infections and complication codes - Patient Safety Indicators - Coded data elements affecting Patient Safety Indicators |
| Medical record documentation | 19.17% | - Types of physician queries - Documentation requiring clarification - Health record elements used for diagnosis and procedure code assignment - Addressing diagnoses without clinical support - When a physician query is warranted - Translating clinical indicators into compliant queries - Compliant and noncompliant queries - Physician query formats - Situations in which queries are not appropriate - ACDIS/AHIMA Guidelines for Achieving a Compliant Query Practice - Clinical indicators - Provider role and diagnosis code assignment |
| Healthcare regulations, reimbursement, and documentation requirements related to the IPPS | 12.5% | - Documentation and medical necessity of setting - Case mix index (CMI) - Inpatient admission criteria and CMS Two-Midnight Rule - Documentation impact on IPPS reimbursement - Complication/comorbidity (CC) - Coding and billing practices vulnerable to denial - IPPS and its updates and revisions - Medicare Severity Diagnosis Related Groups (MS-DRGs) - Medicare contractors and their impact on CDI - Medical staff and clinical staff documentation responsibilities - Major complication/comorbidity (MCC) - Principal diagnosis and medical necessity |
| Communication skills | 9.17% | - Reconciling CDI working DRGs with final coded DRGs - Educational presentations for healthcare departments and administration - Verbal versus written physician communication - Roles and responsibilities of CDI specialists - Physician education forms and tools - Effective and non-confrontational physician communication - Roles and responsibilities of coders working with CDI departments |
| Anatomy and physiology, pathophysiology, pharmacology, and medical terminology | 19.17% | - Injuries, poisonings, and toxic effects of drugs - Diseases and disorders of the respiratory system - Infectious and parasitic diseases - Diseases and disorders of the skin, subcutaneous tissue, and breast - Endocrine, nutritional, and metabolic diseases and disorders - Diseases and disorders of the kidney and urinary tract - Standard medical abbreviations - Mental diseases and disorders - HIV infections - Diseases and disorders of the blood and blood-forming organs and immunological disorders - Diagnostic tests as clinical indicators - Pharmaceuticals and disease processes - Alcohol/drug use and alcohol/drug-induced organic brain disorders - Myeloproliferative diseases and disorders and poorly differentiated neoplasms - Diseases and disorders of the digestive system - Diseases and disorders of the musculoskeletal system - Diseases and disorders of the circulatory system - Diseases and disorders of the hepatobiliary system - Clinical indicators and query opportunities by Major Diagnostic Category - Diseases and disorders of the nervous system - Medications as clinical indicators |
| Healthcare facility CDI program analysis | 8.33% | - High-frequency DRGs - Hospital-specific financial data - Severity of illness and risk of mortality - Case mix index (CMI) - PEPPER data - CDI specialist productivity metrics - Publicly reported data - Provider response rates - CDI program forecasting - CC/MCC capture - Tracking and trending physician, department, and hospital performance - Basic computer and software application skills - Hospital Value-Based Purchasing measures - Patient Safety Indicators - Physician performance measurement |
| Official Guidelines for Coding and Reporting | 14.17% | - Principal diagnosis assignment - Secondary diagnosis assignment - Coding guidelines for principal diagnosis selection - Hospital-acquired conditions - AHA Coding Clinic - Working DRG assignment for multiple diagnoses - Official Guidelines for Coding and Reporting updates - Present on admission indicators - Discharge dispositions and transfers |
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NEW QUESTION # 76
A patient's past medical history lists remote peptic ulcer disease. During the current admission, the condition receives no evaluation, treatment, diagnostic workup, extended length of stay, or increased nursing monitoring. Which statement is MOST accurate?
Answer: C
Explanation:
The remote peptic ulcer disease generally does not meet the definition of a reportable secondary diagnosis for this hospitalization because it does not affect current patient care.
For inpatient reporting, additional diagnoses include clinically significant conditions that coexist at admission or develop subsequently and affect care through factors such as clinical evaluation, therapeutic treatment, diagnostic procedures, extended length of stay, or increased nursing care and monitoring.
Merely appearing in a past medical history or problem list does not make a condition reportable. The condition must satisfy applicable secondary-diagnosis criteria or another specific coding instruction.
This principle prevents the coded record from becoming populated with historical conditions having no relevance to the current hospitalization. It also underscores why CDI review should focus on diagnoses that meaningfully characterize the current episode of care.
Whether a diagnosis is classified as a CC or MCC is a separate MS-DRG concept. A diagnosis must first be appropriately reportable before its severity classification becomes relevant.
The CCDS outline specifically requires application of both principal- and secondary-diagnosis reporting principles.
CCDS Reference Topics: Additional diagnoses; clinically significant secondary conditions; historical diagnoses; resource utilization.
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NEW QUESTION # 77
A patient with type 2 diabetes mellitus is admitted with stage 4 chronic kidney disease. The physician documents both conditions but does not explicitly state that the CKD is caused by diabetes. No documentation indicates that the conditions are unrelated. Which of the following is the MOST appropriate coding approach?
Answer: C
Explanation:
ICD-10-CM permits a presumed causal relationship between diabetes mellitus and certain conditions indexed under "diabetes, with," including chronic kidney disease. Therefore, when diabetes and CKD are both documented and the provider has not specifically indicated that they are unrelated, the diabetes-with-CKD combination code is assigned together with an additional code identifying the CKD stage.
For type 2 diabetes, diabetic CKD is classified to E11.22, while an N18.- code identifies the documented CKD stage. In this scenario, stage 4 CKD would be additionally represented by the appropriate stage-specific N18 code.
A query is not routinely necessary simply to obtain wording such as "diabetic CKD" when the classification itself establishes the presumed relationship. However, clarification would be appropriate if documentation explicitly states another unrelated etiology or contains contradictory information.
This distinction is important for CDI because excessive querying can create unnecessary provider burden.
CDI specialists must understand which diagnostic relationships require explicit provider linkage and which are established through ICD-10-CM conventions.
The FY 2026 Official Guidelines remain applicable to discharges through September 30, 2026.
CCDS Reference Topics: Diabetes; CKD; presumed causal relationships; combination codes; coding conventions.
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NEW QUESTION # 78
Hospital A is developing a query policy. Open-ended queries will be encouraged. The provider is expected to document on the query form, which will be retained as part of the health record. Hospital A will remove any unanswered queries and shred them to avoid any incomplete forms within the health record. Which of the following is considered a high-risk query practice?
Answer: C
Explanation:
The high-risk practice is destroying unanswered queries. Query retention should be governed by an established organizational policy and should not depend on whether the provider answers the query.
Selectively destroying unanswered queries can create significant compliance, audit, and record-integrity concerns because it removes evidence of the documentation-clarification process.
ACDIS/AHIMA guidance has consistently required organizations to establish query-retention policies.
Queries may be retained as part of the permanent health record or maintained as a retrievable business record according to organizational policy and legal requirements. The current 2026 ACDIS/AHIMA query practice guidance supersedes all previous editions, reinforcing the importance of a standardized, defensible query process.
Keeping queries in the health record is not inherently problematic when policy defines them as part of that record. Likewise, a new diagnosis may be included in a multiple-choice query when it is supported by patient- specific clinical indicators and the choices remain nonleading. A yes/no query can also be compliant in defined circumstances, such as clarification of a diagnosis or relationship already documented.
Selective destruction is therefore the clear compliance risk.
CCDS Reference Topics: Query retention; compliance; organizational query policy; audit integrity.
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NEW QUESTION # 79
Which of the following is included among the FY 2026 Hospital-Acquired Condition Reduction Program measures?
Answer: D
Explanation:
CMS PSI 90, the Patient Safety and Adverse Events Composite, is one of the six measures used in the FY
2026 HAC Reduction Program.
CMS states that the program uses one claims-based patient-safety composite-PSI 90-plus five healthcare- associated infection measures: CLABSI, CAUTI, colon and abdominal hysterectomy surgical-site infection, MRSA bacteremia, and C. difficile infection.
Case mix index is an MS-DRG resource-intensity statistic and is not a HACRP quality measure. Query- response rate is an internal CDI performance metric. Patient-experience measures belong to other CMS quality frameworks, including Hospital VBP, rather than constituting a HACRP measure.
For FY 2026, hospitals with Total HAC Scores above the 75th percentile-effectively the worst-performing quartile-are subject to a 1% payment reduction under the program.
A CDI specialist should also distinguish HACRP from the separate HAC/POA payment provision. CMS explicitly identifies them as distinct programs, even though both involve hospital-acquired conditions.
CCDS Reference Topics: HACRP; PSI 90; healthcare-associated infections; patient safety; quality reimbursement.
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NEW QUESTION # 80
Which CMS program can reduce an eligible hospital's Medicare base operating DRG payments by as much as
3% because of excess readmissions?
Answer: D
Explanation:
The Hospital Readmissions Reduction Program (HRRP) reduces payments to applicable hospitals with excess readmissions for specified conditions and procedures. CMS calculates a payment adjustment factor ranging from 1.0 to 0.97, meaning the maximum reduction is 3%.
The adjustment applies to applicable Medicare fee-for-service base operating DRG payments rather than solely to the readmission cases themselves.
This differs from the HAC Reduction Program, which applies a 1% reduction to hospitals in the worst- performing quartile based on defined hospital-acquired-condition measures. Hospital Value-Based Purchasing uses another methodology in which 2% of participating hospitals' base operating DRG payments funds value- based incentive payments.
For CDI professionals, readmission programs demonstrate how clinical documentation can influence more than individual MS-DRG reimbursement. Accurate documentation of comorbidities, principal diagnoses, complications, discharge circumstances, and disease severity contributes to reliable risk-adjusted data.
However, CDI intervention must remain focused on clinical accuracy rather than attempting to alter readmission metrics through unsupported diagnoses.
CCDS Reference Topics: HRRP; readmissions; quality reimbursement; IPPS; risk adjustment.
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NEW QUESTION # 81
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