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| Section | Weight | Objectives |
|---|---|---|
| Topic 1: Communication skills | 9.17% | - Reconciling CDI working DRGs with final coded DRGs - Verbal versus written physician communication - Effective and non-confrontational physician communication - Roles and responsibilities of coders working with CDI departments - Physician education forms and tools - Educational presentations for healthcare departments and administration - Roles and responsibilities of CDI specialists |
| Topic 2: Professionalism, ethics, and compliance | 9.17% | - CDI department goals beyond reimbursement - Medical record confidentiality - Potential DRG creep - Compliance risks indicated by PEPPER - DRG compliance initiatives - Leading queries |
| Topic 3: Healthcare facility CDI program analysis | 8.33% | - Patient Safety Indicators - Publicly reported data - CDI program forecasting - Case mix index (CMI) - Hospital-specific financial data - CC/MCC capture - Basic computer and software application skills - Tracking and trending physician, department, and hospital performance - Physician performance measurement - High-frequency DRGs - Provider response rates - Severity of illness and risk of mortality - CDI specialist productivity metrics - Hospital Value-Based Purchasing measures - PEPPER data |
| Topic 4: Official Guidelines for Coding and Reporting | 14.17% | - Discharge dispositions and transfers - Principal diagnosis assignment - Official Guidelines for Coding and Reporting updates - AHA Coding Clinic - Present on admission indicators - Hospital-acquired conditions - Secondary diagnosis assignment - Coding guidelines for principal diagnosis selection - Working DRG assignment for multiple diagnoses |
| Topic 5: Healthcare regulations, reimbursement, and documentation requirements related to the IPPS | 12.5% | - Inpatient admission criteria and CMS Two-Midnight Rule - Medical staff and clinical staff documentation responsibilities - Complication/comorbidity (CC) - Case mix index (CMI) - Documentation impact on IPPS reimbursement - Medicare Severity Diagnosis Related Groups (MS-DRGs) - Principal diagnosis and medical necessity - Documentation and medical necessity of setting - Coding and billing practices vulnerable to denial - Major complication/comorbidity (MCC) - Medicare contractors and their impact on CDI - IPPS and its updates and revisions |
| Topic 6: Impact of reportable diagnoses on quality of care | 8.33% | - Patient Safety Indicators - Documentation and code assignment impact on mortality index - Quality data from record abstraction and claims data - Hospital-Acquired Condition Reduction Program - Hospital Readmissions Reduction Program - Mortality reviews and observed/expected ratios - 30-day mortality measures - Hospital Inpatient Quality Reporting Program - Healthcare-associated infections and complication codes - Hospital Value-Based Purchasing - CDI impact on Hospital Value-Based Purchasing - Coded data elements affecting Patient Safety Indicators |
| Topic 7: Anatomy and physiology, pathophysiology, pharmacology, and medical terminology | 19.17% | - Standard medical abbreviations - Diseases and disorders of the kidney and urinary tract - Mental diseases and disorders - Diseases and disorders of the musculoskeletal system - Myeloproliferative diseases and disorders and poorly differentiated neoplasms - Diseases and disorders of the blood and blood-forming organs and immunological disorders - Diseases and disorders of the hepatobiliary system - Pharmaceuticals and disease processes - Infectious and parasitic diseases - Diseases and disorders of the nervous system - Clinical indicators and query opportunities by Major Diagnostic Category - Diseases and disorders of the respiratory system - Diseases and disorders of the digestive system - Injuries, poisonings, and toxic effects of drugs - Diseases and disorders of the skin, subcutaneous tissue, and breast - Alcohol/drug use and alcohol/drug-induced organic brain disorders - HIV infections - Endocrine, nutritional, and metabolic diseases and disorders - Medications as clinical indicators - Diagnostic tests as clinical indicators - Diseases and disorders of the circulatory system |
| Topic 8: Medical record documentation | 19.17% | - Situations in which queries are not appropriate - Addressing diagnoses without clinical support - Physician query formats - Types of physician queries - Translating clinical indicators into compliant queries - ACDIS/AHIMA Guidelines for Achieving a Compliant Query Practice - When a physician query is warranted - Provider role and diagnosis code assignment - Documentation requiring clarification - Clinical indicators - Health record elements used for diagnosis and procedure code assignment - Compliant and noncompliant queries |
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NEW QUESTION # 92
A patient with dysphagia after a recent stroke develops fever, hypoxia, and a right lower-lobe infiltrate. The physician documents "pneumonia." Speech therapy documents repeated aspiration with oral intake. What is the MOST appropriate CDI action?
Answer: B
Explanation:
The record presents a legitimate opportunity to clarify the type or etiology of pneumonia, particularly whether aspiration contributed to the pulmonary infection. Dysphagia following stroke, documented aspiration during oral intake, fever, hypoxia, and a dependent-lobe infiltrate form a clinically relevant pattern.
However, the CDI specialist cannot independently convert unspecified pneumonia into aspiration pneumonia.
Likewise, the speech-language pathologist can provide valuable clinical evidence regarding swallowing dysfunction and aspiration risk, but that documentation does not independently establish the medical diagnosis of aspiration pneumonia for coding purposes.
A compliant query should objectively present the pertinent indicators and allow the provider to identify aspiration pneumonia, another pneumonia type, pneumonitis, another condition, or inability to determine.
Automatically assigning both bacterial and aspiration pneumonia would also be inappropriate because neither bacterial etiology nor a separate second pneumonia diagnosis has been established.
The current ACDIS/AHIMA guidance emphasizes that queries should arise from the clinical record and preserve the provider's independent judgment rather than directing a preferred diagnosis.
CCDS Reference Topics: Pneumonia specificity; aspiration; dysphagia; interdisciplinary documentation; compliant query development.
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NEW QUESTION # 93
A registered dietitian documents severe malnutrition based on substantial weight loss, severe muscle depletion, and prolonged inadequate energy intake. The attending physician documents only "poor oral intake." What is the BEST action for the CDI specialist?
Answer: C
Explanation:
The appropriate action is to query the provider regarding the patient's nutritional diagnosis. The dietitian's assessment supplies important clinical evidence, but the associated diagnosis of malnutrition generally must be documented by an appropriate provider before the diagnosis code is assigned.
The FY 2026 ICD-10-CM Official Guidelines permit selected elements to come from non-provider clinicians-such as BMI, pressure-ulcer stage, coma scale, NIH Stroke Scale, certain social determinants, and other specifically identified exceptions. Malnutrition diagnosis itself is not simply assigned solely from a dietitian's diagnostic statement under this general rule.
Ignoring the dietitian's findings would also be inappropriate. CDI review should integrate multidisciplinary documentation because such documentation can reveal valid clarification opportunities. Severe weight loss, reduced intake, and documented muscle depletion provide a clinical basis for a neutral query.
The query should not state that severe malnutrition "must" be documented because it is an MCC. Instead, it should present the relevant nutrition findings and allow the provider to determine the diagnosis, including severe malnutrition, another level of malnutrition, another cause, or inability to determine.
CCDS Reference Topics: Malnutrition; multidisciplinary documentation; provider diagnosis requirements; clinical indicators.
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NEW QUESTION # 94
A patient with active breast cancer is admitted solely to receive a scheduled cycle of antineoplastic chemotherapy. No complication or acute disease process is responsible for the admission. Which diagnosis is generally sequenced first?
Answer: B
Explanation:
When an inpatient encounter is solely for administration of chemotherapy, the encounter-for-chemotherapy code is generally sequenced first, followed by the code identifying the malignancy being treated.
This represents an important exception to the usual expectation that the underlying disease is the principal diagnosis. The circumstances of admission are specifically treatment administration rather than management of an acute complication of the malignancy.
If, however, the patient were admitted because of a complication-such as chemotherapy-induced neutropenic fever, dehydration, anemia, or another adverse effect-the principal-diagnosis analysis would follow the applicable guideline for that condition rather than automatically using the chemotherapy encounter code.
Similarly, if chemotherapy were administered incidentally during a hospitalization principally required for another condition, the encounter-for-chemotherapy code would not displace the actual principal diagnosis.
CDI professionals should therefore distinguish planned treatment encounters from admissions caused by complications of treatment or malignancy.
Clear documentation regarding the reason for admission, cancer site, treatment intent, metastatic disease, and complications helps support proper sequencing and accurate oncology data.
CCDS Reference Topics: Antineoplastic chemotherapy; encounter codes; neoplasm sequencing; principal diagnosis; oncology documentation.
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NEW QUESTION # 95
A patient without chronic hypercapnia develops severe respiratory distress. ABG results are pH 7.19, PaCO#
74 mmHg, and PaO# 60 mmHg. The patient requires emergent BiPAP. Which condition is MOST strongly supported for clarification?
Answer: B
Explanation:
The findings strongly support clarification of acute hypercapnic respiratory failure. PaCO# of 74 mmHg represents marked carbon dioxide retention, while pH 7.19 demonstrates significant respiratory acidemia. The patient is also hypoxemic and requires urgent noninvasive ventilatory assistance.
Because there is no documented chronic hypercapnic baseline, the available information primarily supports an acute process rather than chronic respiratory failure.
Acute hypercapnia occurs when alveolar ventilation becomes insufficient to eliminate carbon dioxide.
Potential causes include COPD or asthma exacerbation, central nervous system depression, neuromuscular weakness, obesity hypoventilation, airway obstruction, or severe fatigue.
BiPAP provides positive-pressure ventilatory support and can improve alveolar ventilation, decrease work of breathing, and lower PaCO#.
The CDI specialist should not independently establish respiratory failure solely from an ABG. However, the combination of severe physiologic abnormality, respiratory distress, and escalation to BiPAP supplies a strong basis for provider clarification when no corresponding diagnosis is documented.
Metabolic alkalosis would ordinarily involve primary bicarbonate elevation with alkalemia rather than profound respiratory acidemia.
CCDS Reference Topics: Acute respiratory failure; hypercapnia; ABG interpretation; noninvasive ventilation; clinical indicators.
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NEW QUESTION # 96
Which of the following is considered by CMS to be a HAC requiring MS-DRG adjustment if not POA?
Answer: D
Explanation:
CMS specifically includes deep vein thrombosis and pulmonary embolism following certain orthopedic procedures, including total knee replacement and hip replacement, among Hospital-Acquired Conditions subject to the HAC/POA payment provisions. Therefore, option C is correct.
Under the IPPS HAC payment policy, qualifying conditions that were not present on admission may lose their normal CC/MCC effect for MS-DRG assignment when all applicable criteria are met. This makes accurate POA determination essential in CDI and coding.
Pressure ulcers are also part of the HAC framework, but the CMS category historically applies specifically to Stage III and Stage IV pressure ulcers. An unstageable pressure ulcer does not automatically satisfy the Stage III/IV HAC category merely because it is severe or clinically significant. CMS materials distinguish an unstageable ulcer from a documented Stage III or IV ulcer.
Postoperative pneumonia and septic shock are not, by themselves, the specified HAC category represented by the answer choices.
The CCDS blueprint specifically requires candidates to identify CMS-designated HACs and understand the effect of POA assignment on payment.
CCDS Reference Topics: IPPS; Hospital-Acquired Conditions; POA; MS-DRG adjustment.
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NEW QUESTION # 97
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