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| Section | Weight | Objectives |
|---|---|---|
| Professionalism, ethics, and compliance | 9.17% | - Medical record confidentiality - CDI department goals beyond reimbursement - Potential DRG creep - DRG compliance initiatives - Leading queries - Compliance risks indicated by PEPPER |
| Official Guidelines for Coding and Reporting | 14.17% | - Principal diagnosis assignment - Present on admission indicators - AHA Coding Clinic - Discharge dispositions and transfers - Secondary diagnosis assignment - Working DRG assignment for multiple diagnoses - Hospital-acquired conditions - Official Guidelines for Coding and Reporting updates - Coding guidelines for principal diagnosis selection |
| Impact of reportable diagnoses on quality of care | 8.33% | - 30-day mortality measures - Healthcare-associated infections and complication codes - Hospital Readmissions Reduction Program - Mortality reviews and observed/expected ratios - Documentation and code assignment impact on mortality index - Hospital-Acquired Condition Reduction Program - Quality data from record abstraction and claims data - Hospital Value-Based Purchasing - CDI impact on Hospital Value-Based Purchasing - Hospital Inpatient Quality Reporting Program - Patient Safety Indicators - Coded data elements affecting Patient Safety Indicators |
| Communication skills | 9.17% | - Reconciling CDI working DRGs with final coded DRGs - Educational presentations for healthcare departments and administration - Physician education forms and tools - Effective and non-confrontational physician communication - Roles and responsibilities of CDI specialists - Roles and responsibilities of coders working with CDI departments - Verbal versus written physician communication |
| Healthcare regulations, reimbursement, and documentation requirements related to the IPPS | 12.5% | - Medicare contractors and their impact on CDI - Medical staff and clinical staff documentation responsibilities - Complication/comorbidity (CC) - Documentation impact on IPPS reimbursement - Case mix index (CMI) - Inpatient admission criteria and CMS Two-Midnight Rule - Major complication/comorbidity (MCC) - Principal diagnosis and medical necessity - Coding and billing practices vulnerable to denial - Documentation and medical necessity of setting - IPPS and its updates and revisions - Medicare Severity Diagnosis Related Groups (MS-DRGs) |
| Healthcare facility CDI program analysis | 8.33% | - Publicly reported data - CDI specialist productivity metrics - Physician performance measurement - Provider response rates - Case mix index (CMI) - Tracking and trending physician, department, and hospital performance - CC/MCC capture - PEPPER data - High-frequency DRGs - Hospital Value-Based Purchasing measures - Severity of illness and risk of mortality - Patient Safety Indicators - CDI program forecasting - Basic computer and software application skills - Hospital-specific financial data |
| Medical record documentation | 19.17% | - Documentation requiring clarification - Types of physician queries - When a physician query is warranted - Situations in which queries are not appropriate - Provider role and diagnosis code assignment - Clinical indicators - Compliant and noncompliant queries - Physician query formats - ACDIS/AHIMA Guidelines for Achieving a Compliant Query Practice - Translating clinical indicators into compliant queries - Health record elements used for diagnosis and procedure code assignment - Addressing diagnoses without clinical support |
| Anatomy and physiology, pathophysiology, pharmacology, and medical terminology | 19.17% | - Diseases and disorders of the circulatory system - Diseases and disorders of the blood and blood-forming organs and immunological disorders - Medications as clinical indicators - Diseases and disorders of the kidney and urinary tract - HIV infections - Diseases and disorders of the digestive system - Standard medical abbreviations - Diseases and disorders of the respiratory system - Diseases and disorders of the nervous system - Endocrine, nutritional, and metabolic diseases and disorders - Infectious and parasitic diseases - Diseases and disorders of the hepatobiliary system - Alcohol/drug use and alcohol/drug-induced organic brain disorders - Diagnostic tests as clinical indicators - Diseases and disorders of the musculoskeletal system - Diseases and disorders of the skin, subcutaneous tissue, and breast - Injuries, poisonings, and toxic effects of drugs - Clinical indicators and query opportunities by Major Diagnostic Category - Mental diseases and disorders - Myeloproliferative diseases and disorders and poorly differentiated neoplasms - Pharmaceuticals and disease processes |
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NEW QUESTION # 136
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 # 137
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: B
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 # 138
Which statement BEST defines the principal diagnosis for an inpatient hospitalization?
Answer: D
Explanation:
The principal diagnosis is the condition established after study to be chiefly responsible for occasioning the patient's admission to the hospital for care. This is the UHDDS definition used in the ICD-10-CM Official Guidelines for inpatient principal-diagnosis selection.
"After study" is critical. The diagnosis initially suspected in the emergency department may change after diagnostic testing, consultation, treatment response, surgery, pathology, or other evaluation. The final principal diagnosis therefore may differ from the first diagnosis documented.
Relative weight does not determine principal diagnosis. A hospital cannot select a higher-paying condition merely because it produces a more favorable MS-DRG. Similarly, medication volume is not a principal- diagnosis criterion.
For CDI specialists, principal-diagnosis review requires understanding the circumstances surrounding admission, the diagnostic workup, final provider documentation, sequencing conventions, and any chapter- specific guidelines. When two conditions are documented and it is unclear which chiefly occasioned the admission, a provider query may be warranted.
The CCDS content outline specifically tests the principles and application of principal-diagnosis assignment.
CCDS Reference Topics: Principal diagnosis; UHDDS; inpatient sequencing; working MS-DRG.
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NEW QUESTION # 139
Based on the AHIMA/ACDIS Practice Brief Guidelines for Achieving a Compliant Query Practice, a leading query is one that:
Answer: C
Explanation:
A query becomes problematic when it directs or influences the provider toward a diagnosis that is not supported by the patient's clinical record. Therefore, option C most accurately represents the leading-query concept in this answer set. A compliant query must be based on patient-specific clinical indicators and must preserve the provider's independent clinical judgment.
A multiple-choice query may include a diagnosis not previously documented when that diagnosis is supported by the clinical indicators and when reasonable alternatives are also offered. ACDIS/AHIMA guidance has specifically recognized that presenting a clinically supported new diagnosis among neutral choices does not automatically make the query leading.
Likewise, the timing of a query while a provider is documenting does not make it leading. Cause-and-effect clarification may also be addressed using an appropriate query format when both conditions are documented and the relationship remains uncertain.
The current 2026 ACDIS/AHIMA Guidelines for Achieving a Compliant Query Practice supersede the prior versions and continue to establish compliant provider-query practice as a foundational CDI standard. Queries must be clinically supported, noncoercive, and constructed without reference to reimbursement or other desired outcomes.
CCDS Reference Topics: Leading queries; clinical indicators; compliant query construction; provider independence.
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NEW QUESTION # 140
A patient with COPD normally has a PaCO# of approximately 45 mmHg. The patient is admitted with increasing somnolence and respiratory distress. Arterial blood gas results are pH 7.27, PaCO# 68 mmHg, and PaO# 58 mmHg. BiPAP is initiated. Which condition is MOST appropriate for the CDI specialist to consider as a clarification opportunity?
Answer: A
Explanation:
The findings strongly support a clarification opportunity for acute hypercapnic respiratory failure. The patient has a substantial acute rise in PaCO# above the documented baseline, respiratory acidemia with a pH of 7.27, hypoxemia, altered mental status, respiratory distress, and escalation to noninvasive ventilatory support.
In chronic CO# retention, renal compensation commonly increases serum bicarbonate and may allow a relatively preserved pH. A pronounced fall in pH in conjunction with a significant increase in PaCO# suggests an acute ventilatory deterioration. The need for BiPAP provides additional evidence of clinically significant respiratory compromise.
Option C is incorrect because the acidemia is driven primarily by elevated carbon dioxide, indicating respiratory rather than metabolic acidosis. Option A fails to capture the apparent acute deterioration from the patient's baseline. Option D is inconsistent with the physiologic abnormalities and treatment intensity.
The CDI specialist must still obtain provider documentation rather than independently diagnose respiratory failure. The CCDS examination specifically includes acute/chronic respiratory failure, COPD, ventilation support, and diagnostic-test interpretation among expected clinical competencies.
CCDS Reference Topics: Acute respiratory failure; hypercapnia; ABG interpretation; COPD; noninvasive ventilation.
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NEW QUESTION # 141
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