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| Section | Weight | Objectives |
|---|---|---|
| Healthcare facility CDI program analysis | 8.33% | - Tracking and trending physician, department, and hospital performance - Hospital-specific financial data - High-frequency DRGs - Publicly reported data - CDI program forecasting - CDI specialist productivity metrics - Physician performance measurement - CC/MCC capture - Severity of illness and risk of mortality - Patient Safety Indicators - Case mix index (CMI) - Provider response rates - PEPPER data - Basic computer and software application skills - Hospital Value-Based Purchasing measures |
| Anatomy and physiology, pathophysiology, pharmacology, and medical terminology | 19.17% | - Mental diseases and disorders - Diseases and disorders of the musculoskeletal system - Diseases and disorders of the kidney and urinary tract - Standard medical abbreviations - Diseases and disorders of the hepatobiliary system - HIV infections - Diseases and disorders of the circulatory system - Medications as clinical indicators - Diseases and disorders of the skin, subcutaneous tissue, and breast - Alcohol/drug use and alcohol/drug-induced organic brain disorders - Diseases and disorders of the respiratory system - Endocrine, nutritional, and metabolic diseases and disorders - Pharmaceuticals and disease processes - Clinical indicators and query opportunities by Major Diagnostic Category - Diseases and disorders of the blood and blood-forming organs and immunological disorders - Diseases and disorders of the nervous system - Diseases and disorders of the digestive system - Diagnostic tests as clinical indicators - Injuries, poisonings, and toxic effects of drugs - Infectious and parasitic diseases - Myeloproliferative diseases and disorders and poorly differentiated neoplasms |
| Professionalism, ethics, and compliance | 9.17% | - Medical record confidentiality - DRG compliance initiatives - Potential DRG creep - CDI department goals beyond reimbursement - Leading queries - Compliance risks indicated by PEPPER |
| Impact of reportable diagnoses on quality of care | 8.33% | - 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 - Hospital Value-Based Purchasing - 30-day mortality measures - Coded data elements affecting Patient Safety Indicators - Hospital-Acquired Condition Reduction Program - CDI impact on Hospital Value-Based Purchasing - Patient Safety Indicators - Hospital Inpatient Quality Reporting Program - Healthcare-associated infections and complication codes |
| Official Guidelines for Coding and Reporting | 14.17% | - AHA Coding Clinic - Present on admission indicators - Hospital-acquired conditions - Official Guidelines for Coding and Reporting updates - Secondary diagnosis assignment - Discharge dispositions and transfers - Coding guidelines for principal diagnosis selection - Principal diagnosis assignment - Working DRG assignment for multiple diagnoses |
| Healthcare regulations, reimbursement, and documentation requirements related to the IPPS | 12.5% | - Medical staff and clinical staff documentation responsibilities - Coding and billing practices vulnerable to denial - Complication/comorbidity (CC) - Major complication/comorbidity (MCC) - Documentation impact on IPPS reimbursement - Medicare Severity Diagnosis Related Groups (MS-DRGs) - Case mix index (CMI) - Principal diagnosis and medical necessity - Inpatient admission criteria and CMS Two-Midnight Rule - Documentation and medical necessity of setting - Medicare contractors and their impact on CDI - IPPS and its updates and revisions |
| Medical record documentation | 19.17% | - Types of physician queries - When a physician query is warranted - Compliant and noncompliant queries - Health record elements used for diagnosis and procedure code assignment - Physician query formats - Clinical indicators - Translating clinical indicators into compliant queries - Situations in which queries are not appropriate - Provider role and diagnosis code assignment - ACDIS/AHIMA Guidelines for Achieving a Compliant Query Practice - Documentation requiring clarification - Addressing diagnoses without clinical support |
| Communication skills | 9.17% | - Physician education forms and tools - Educational presentations for healthcare departments and administration - Roles and responsibilities of CDI specialists - Roles and responsibilities of coders working with CDI departments - Reconciling CDI working DRGs with final coded DRGs - Effective and non-confrontational physician communication - Verbal versus written physician communication |
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NEW QUESTION # 60
Which pressure-ulcer category is specifically included in the traditional CMS HAC payment policy when the condition is not present on admission?
Answer: C
Explanation:
CMS's Hospital-Acquired Condition payment framework specifically identifies Stage III and Stage IV pressure ulcers among the defined HAC categories when applicable conditions are not present on admission.
The distinction is important because not every pressure injury automatically triggers HAC payment treatment.
Stage and POA status therefore require accurate documentation.
A hospital-acquired pressure ulcer remains reportable even when HAC payment provisions apply. CMS does not instruct hospitals to suppress or omit such conditions. Instead, defined HAC diagnoses that are not POA may lose the CC/MCC payment effect they otherwise would contribute to the MS-DRG, subject to applicable grouper rules.
The CDI specialist should ensure that wound location, laterality when relevant, stage, progression, and timing are accurately documented. Qualified wound-care nurse documentation may be used for pressure-ulcer staging under the ICD-10-CM non-provider documentation exception, while the diagnosis itself remains subject to provider-documentation requirements.
CDI professionals must also distinguish the HAC/POA MS-DRG payment provision from the separate HAC Reduction Program, which reduces applicable hospital payments by 1% for hospitals in the worst-performing quartile.
CCDS Reference Topics: HACs; pressure ulcers; POA; MS-DRG adjustment; wound documentation.
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NEW QUESTION # 61
A neurologist documents acute cerebral infarction. A qualified stroke nurse records the NIH Stroke Scale score in the medical record. Which statement is MOST accurate?
Answer: C
Explanation:
ICD-10-CM permits the NIH Stroke Scale score to be reported from documentation by an appropriate clinician other than the provider responsible for establishing the diagnosis. The underlying stroke diagnosis itself must be appropriately documented by the provider.
This is similar to other specified exceptions such as BMI, pressure-ulcer stage, coma scale values, and certain additional clinical elements for which qualified non-provider documentation may support code assignment.
The exception does not mean that a stroke nurse can independently establish cerebral infarction for coding.
Rather, once the provider has documented the stroke, the nurse's formal NIHSS assessment can supply the standardized severity measurement.
This approach recognizes that specially trained clinical professionals routinely collect and document these structured measurements as part of patient care.
If multiple NIHSS values are documented, the applicable coding instructions and timing requirements should be followed rather than simply selecting the highest score because it produces a different code.
For CDI professionals, awareness of these non-provider documentation exceptions prevents unnecessary physician queries while ensuring that important severity information is not lost.
CCDS Reference Topics: NIH Stroke Scale; cerebral infarction; non-provider documentation; coding exceptions; stroke severity.
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NEW QUESTION # 62
A patient's hemoglobin decreases from 13.1 g/dL before surgery to 7.4 g/dL afterward. Estimated intraoperative blood loss is 1,200 mL, and the patient receives two units of packed red blood cells. The physician documents only "postoperative anemia." Which clarification is MOST appropriate?
Answer: A
Explanation:
The significant hemoglobin decline, documented surgical blood loss, and transfusion requirement create a strong clinical basis to clarify whether the patient has acute blood loss anemia or another form of postoperative anemia.
However, neither the hemoglobin value nor transfusion independently establishes the diagnosis. The provider must determine the clinical significance and etiology. A postoperative hemoglobin decline can reflect actual hemorrhage, hemodilution, preexisting anemia, expected procedural blood loss, or multiple factors.
A compliant query could present baseline and postoperative hemoglobin levels, estimated blood loss, transfusion, hemodynamic findings, and relevant treatment, then ask the provider to characterize the anemia.
The CDI specialist should also distinguish anemia from a postprocedural complication. Even if acute blood loss anemia is documented, that does not automatically mean a surgical complication occurred. Complication status may require separate provider clarification depending on the record.
Hemolytic anemia has a different pathophysiology involving red-cell destruction, while chronic iron deficiency cannot be inferred from the acute postoperative course.
CCDS Reference Topics: Acute blood loss anemia; postoperative documentation; transfusion; clinical indicators; complications of care.
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NEW QUESTION # 63
A patient is admitted with fever, productive cough, and hypotension. The attending physician documents sepsis due to pneumonia. Acute kidney injury develops and is documented as due to sepsis. Which of the following is the MOST appropriate sequencing concept?
Answer: D
Explanation:
When sepsis due to a localized infection is responsible for the admission, the systemic infection is generally sequenced first, followed by the localized infection. If acute organ dysfunction is documented as associated with the sepsis, severe sepsis coding additionally requires the appropriate R65.2- code and code(s) for the acute organ dysfunction.
The severe-sepsis code itself is not sequenced as principal diagnosis. The underlying systemic infection precedes it. In this case, the patient's AKI has specifically been linked to sepsis, supporting the severe-sepsis framework.
Pneumonia remains important because it identifies the localized source of infection, but it does not generally precede the systemic infection when sepsis is present on admission and is responsible for the hospitalization.
The CDI specialist should verify that the documentation clearly establishes the relationship between the acute organ dysfunction and sepsis. Organ dysfunction occurring in a patient with sepsis is not automatically attributable to sepsis when another cause is documented or clinically plausible.
The FY 2026 ICD-10-CM Official Guidelines govern these sequencing principles.
CCDS Reference Topics: Sepsis; severe sepsis; principal diagnosis; acute organ dysfunction; sequencing.
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NEW QUESTION # 64
A 34-year-old female was admitted from a group home with uncontrolled diabetes. A CDI specialist must query to specify the patient's mental incapacity since it makes management of the diabetes more difficult.
Which of the following terminology recognized by ICD-10-CM could result in the assignment of a comorbid condition?
Answer: C
Explanation:
Severe intellectual disability is recognized ICD-10-CM terminology and maps to F72, Severe intellectual disabilities. The other phrases are not equivalent standardized ICD-10-CM diagnostic terminology.
This distinction is highly relevant to CDI. Terms used conversationally in the clinical record do not necessarily provide sufficient specificity or map cleanly to reportable ICD-10-CM diagnoses. When a patient's cognitive or developmental condition affects treatment, monitoring, self-management, nursing requirements, or the complexity of care, the CDI specialist should seek clinically appropriate provider documentation using recognized diagnostic terminology.
For FY 2026 MS-DRG logic, CMS identifies F72 as a CC, meaning it can qualify as a complication
/comorbidity when it meets secondary-diagnosis reporting requirements. That does not mean the CDI specialist should query merely for reimbursement impact. The query must be clinically justified by the record and should allow the provider to determine the correct diagnosis.
"Severe mental challenge," "acute mental incapacity," and "acute intellectual disability" do not represent the same codable disease classification.
CCDS Reference Topics: Medical terminology; mental/behavioral and neurodevelopmental disorders; CC recognition; clinically supported query opportunities.
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NEW QUESTION # 65
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