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| Section | Weight | Objectives |
|---|---|---|
| Topic 1: Healthcare regulations, reimbursement, and documentation requirements related to the IPPS | 12.5% | - Documentation impact on IPPS reimbursement - Principal diagnosis and medical necessity - Coding and billing practices vulnerable to denial - Documentation and medical necessity of setting - IPPS and its updates and revisions - Case mix index (CMI) - Medicare contractors and their impact on CDI - Major complication/comorbidity (MCC) - Complication/comorbidity (CC) - Medicare Severity Diagnosis Related Groups (MS-DRGs) - Inpatient admission criteria and CMS Two-Midnight Rule - Medical staff and clinical staff documentation responsibilities |
| Topic 2: Communication skills | 9.17% | - Physician education forms and tools - Roles and responsibilities of CDI specialists - Effective and non-confrontational physician communication - Reconciling CDI working DRGs with final coded DRGs - Verbal versus written physician communication - Educational presentations for healthcare departments and administration - Roles and responsibilities of coders working with CDI departments |
| Topic 3: Medical record documentation | 19.17% | - Addressing diagnoses without clinical support - Health record elements used for diagnosis and procedure code assignment - ACDIS/AHIMA Guidelines for Achieving a Compliant Query Practice - Situations in which queries are not appropriate - Documentation requiring clarification - When a physician query is warranted - Compliant and noncompliant queries - Physician query formats - Types of physician queries - Clinical indicators - Translating clinical indicators into compliant queries - Provider role and diagnosis code assignment |
| Topic 4: Impact of reportable diagnoses on quality of care | 8.33% | - Hospital Inpatient Quality Reporting Program - Hospital Readmissions Reduction Program - CDI impact on Hospital Value-Based Purchasing - Healthcare-associated infections and complication codes - Patient Safety Indicators - Coded data elements affecting Patient Safety Indicators - 30-day mortality measures - Hospital-Acquired Condition Reduction Program - Documentation and code assignment impact on mortality index - Mortality reviews and observed/expected ratios - Quality data from record abstraction and claims data - Hospital Value-Based Purchasing |
| Topic 5: Healthcare facility CDI program analysis | 8.33% | - Severity of illness and risk of mortality - CDI specialist productivity metrics - Publicly reported data - High-frequency DRGs - Case mix index (CMI) - CC/MCC capture - Hospital-specific financial data - CDI program forecasting - Basic computer and software application skills - Patient Safety Indicators - Hospital Value-Based Purchasing measures - Provider response rates - Tracking and trending physician, department, and hospital performance - PEPPER data - Physician performance measurement |
| Topic 6: Anatomy and physiology, pathophysiology, pharmacology, and medical terminology | 19.17% | - Diseases and disorders of the nervous system - Diseases and disorders of the circulatory system - Diseases and disorders of the skin, subcutaneous tissue, and breast - Pharmaceuticals and disease processes - Alcohol/drug use and alcohol/drug-induced organic brain disorders - Standard medical abbreviations - Diagnostic tests as clinical indicators - Diseases and disorders of the kidney and urinary tract - Mental diseases and disorders - Myeloproliferative diseases and disorders and poorly differentiated neoplasms - Medications as clinical indicators - Injuries, poisonings, and toxic effects of drugs - Infectious and parasitic diseases - HIV infections - Clinical indicators and query opportunities by Major Diagnostic Category - Endocrine, nutritional, and metabolic diseases and disorders - Diseases and disorders of the digestive system - Diseases and disorders of the musculoskeletal system - Diseases and disorders of the respiratory system - Diseases and disorders of the blood and blood-forming organs and immunological disorders - Diseases and disorders of the hepatobiliary system |
| Topic 7: Professionalism, ethics, and compliance | 9.17% | - Potential DRG creep - CDI department goals beyond reimbursement - DRG compliance initiatives - Medical record confidentiality - Leading queries - Compliance risks indicated by PEPPER |
| Topic 8: Official Guidelines for Coding and Reporting | 14.17% | - Present on admission indicators - Coding guidelines for principal diagnosis selection - AHA Coding Clinic - Official Guidelines for Coding and Reporting updates - Working DRG assignment for multiple diagnoses - Principal diagnosis assignment - Secondary diagnosis assignment - Discharge dispositions and transfers - Hospital-acquired conditions |
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NEW QUESTION # 108
A patient is admitted with a stage 2 sacral pressure ulcer. During the hospitalization, the ulcer progresses and is documented as stage 3 at the same site. How should the pressure ulcer be reported?
Answer: A
Explanation:
The FY 2026 ICD-10-CM Official Guidelines specifically address a pressure ulcer that progresses to a higher stage during an inpatient admission. Two codes are assigned: one representing the site and stage present on admission and another representing the same ulcer site at the highest stage documented during the hospitalization.
Therefore, this patient's stage 2 sacral pressure ulcer on admission and subsequent progression to stage 3 must both be represented according to the applicable coding instructions.
The distinction is important for both clinical and quality purposes because the record must accurately show what condition existed when the patient entered the hospital and how the wound subsequently evolved.
Coding only the stage 3 ulcer would lose information about its status at admission. Coding only stage 2 would fail to represent the deterioration that occurred during the stay.
Pressure-ulcer staging is also one of the circumstances in which qualified non-provider clinician documentation, such as wound-care nursing documentation, may be used to establish stage when the diagnosis itself is appropriately documented.
For CDI, accurate wound location, stage, progression, and POA documentation are essential because advanced pressure injuries may influence MS-DRG severity and hospital quality reporting.
CCDS Reference Topics: Pressure ulcers; staging; POA; wound-care documentation; Official Guidelines.
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NEW QUESTION # 109
A CDI manager notes that the physician query response rate is 98%, but only 55% of queries are answered before discharge. Which metric should receive the MOST immediate workflow analysis?
Answer: A
Explanation:
The overall response rate is excellent at 98%, but the fact that only 55% of queries are resolved before discharge indicates a meaningful concurrent-workflow issue.
Concurrent CDI is most effective when clarification occurs while the patient remains hospitalized and the physician has immediate access to the clinical context. Delayed responses can contribute to retrospective work, final-bill holds, coding delays, and administrative escalation.
The CDI manager should determine whether delays cluster by provider, specialty, query type, unit, day of week, discharge timing, or electronic-query process. Other factors may include insufficient notification, physician workflow, poor escalation protocols, or queries being issued too late in the stay.
CMI and MCC volume do not directly measure response timeliness and should not substitute for analysis of the actual operational problem.
Importantly, programs should not pressure physicians into rapid but clinically superficial responses. Query timing initiatives must preserve thoughtful provider judgment and compliant communication.
ACDIS identifies medical-record review, communication, query technique, and data-mining/reporting functions among core CCDS competencies.
CCDS Reference Topics: Query timeliness; concurrent CDI; physician engagement; workflow analysis; program metrics.
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NEW QUESTION # 110
A patient is admitted with shortness of breath and dyspnea. Physical examination documents percussion dullness of the chest and decreased breath sounds. A chest x-ray indicates an increase in fluid with complete opacification of the hemithorax and mediastinal shift to the contralateral side. Which of the following conditions should be queried with the physician?
Answer: D
Explanation:
The findings are characteristic of a large or massive pleural effusion. Pleural fluid produces dullness to percussion and diminished breath sounds because fluid within the pleural space reduces normal transmission of respiratory sounds and replaces the normally air-filled acoustic environment.
A sufficiently large effusion can cause complete or near-complete opacification of a hemithorax on chest radiography. Importantly, a large-volume effusion exerts mass effect and can push the mediastinum away from the affected side, producing contralateral mediastinal shift. That combination strongly supports pleural effusion as the appropriate diagnostic clarification.
Pneumonia can produce focal opacity and abnormal breath sounds, but extensive consolidation often causes air bronchograms and typically does not create the same fluid-related contralateral mass effect. Atelectasis can opacify a hemithorax but usually pulls the mediastinum toward the affected side because of volume loss.
Bronchiectasis has different radiographic characteristics, including chronic bronchial dilation. Heart failure may cause pleural effusions but does not itself describe the immediate radiographic abnormality being presented.
A CDI query should seek provider confirmation rather than independently diagnose the effusion.
CCDS Reference Topics: Pleural disease; chest radiographic interpretation; pulmonary clinical indicators; diagnostic clarification.
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NEW QUESTION # 111
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: A
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 # 112
A patient has chronic gastroesophageal reflux disease listed in the past medical history. During the current hospitalization for bacterial pneumonia, GERD receives no clinical evaluation, treatment, diagnostic testing, increased nursing monitoring, or effect on length of stay. Which statement is MOST accurate?
Answer: A
Explanation:
A condition documented in the medical record does not automatically qualify as a reportable secondary diagnosis. For inpatient coding, additional diagnoses generally must be clinically significant during the current hospitalization. Qualifying significance includes clinical evaluation, therapeutic treatment, diagnostic procedures, an extended length of stay, or increased nursing care and/or monitoring.
Here, GERD is merely part of the patient's historical medical background and does not affect current management. Therefore, it generally should not be reported as an additional diagnosis solely because it appears in the past medical history.
Whether a diagnosis is classified as a CC or MCC is a separate issue. A condition must first satisfy applicable reporting requirements before its MS-DRG severity classification matters. CDI specialists should never encourage coding of clinically irrelevant historical conditions merely because they could affect reimbursement.
This principle protects the clinical integrity of coded data and prevents inappropriate inflation of disease burden. CDI review should focus on conditions that meaningfully describe the patient's current hospitalization, treatment requirements, clinical risk, and resource consumption.
CCDS Reference Topics: Reporting additional diagnoses; secondary-diagnosis criteria; medical-record review; resource utilization; coding compliance.
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NEW QUESTION # 113
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