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| Section | Weight | Objectives |
|---|---|---|
| Topic 1: Professionalism, ethics, and compliance | 9.17% | - Leading queries - DRG compliance initiatives - Medical record confidentiality - Compliance risks indicated by PEPPER - CDI department goals beyond reimbursement - Potential DRG creep |
| Topic 2: Medical record documentation | 19.17% | - Compliant and noncompliant queries - Clinical indicators - Situations in which queries are not appropriate - Physician query formats - Documentation requiring clarification - Types of physician queries - Addressing diagnoses without clinical support - ACDIS/AHIMA Guidelines for Achieving a Compliant Query Practice - Provider role and diagnosis code assignment - When a physician query is warranted - Translating clinical indicators into compliant queries - Health record elements used for diagnosis and procedure code assignment |
| Topic 3: Healthcare facility CDI program analysis | 8.33% | - CDI program forecasting - Tracking and trending physician, department, and hospital performance - CDI specialist productivity metrics - PEPPER data - Case mix index (CMI) - Hospital-specific financial data - CC/MCC capture - High-frequency DRGs - Provider response rates - Hospital Value-Based Purchasing measures - Physician performance measurement - Patient Safety Indicators - Severity of illness and risk of mortality - Publicly reported data - Basic computer and software application skills |
| Topic 4: Official Guidelines for Coding and Reporting | 14.17% | - Secondary diagnosis assignment - Discharge dispositions and transfers - Present on admission indicators - Coding guidelines for principal diagnosis selection - Official Guidelines for Coding and Reporting updates - Working DRG assignment for multiple diagnoses - AHA Coding Clinic - Hospital-acquired conditions - Principal diagnosis assignment |
| Topic 5: Communication skills | 9.17% | - Effective and non-confrontational physician communication - Roles and responsibilities of coders working with CDI departments - Verbal versus written physician communication - Roles and responsibilities of CDI specialists - Physician education forms and tools - Educational presentations for healthcare departments and administration - Reconciling CDI working DRGs with final coded DRGs |
| Topic 6: Anatomy and physiology, pathophysiology, pharmacology, and medical terminology | 19.17% | - Diseases and disorders of the skin, subcutaneous tissue, and breast - HIV infections - Myeloproliferative diseases and disorders and poorly differentiated neoplasms - Pharmaceuticals and disease processes - Clinical indicators and query opportunities by Major Diagnostic Category - Alcohol/drug use and alcohol/drug-induced organic brain disorders - Medications as clinical indicators - Endocrine, nutritional, and metabolic diseases and disorders - Diseases and disorders of the hepatobiliary system - Injuries, poisonings, and toxic effects of drugs - Diagnostic tests as clinical indicators - Diseases and disorders of the kidney and urinary tract - Diseases and disorders of the nervous system - Standard medical abbreviations - Diseases and disorders of the circulatory system - Diseases and disorders of the digestive system - Mental diseases and disorders - Diseases and disorders of the blood and blood-forming organs and immunological disorders - Diseases and disorders of the respiratory system - Infectious and parasitic diseases - Diseases and disorders of the musculoskeletal system |
| Topic 7: Healthcare regulations, reimbursement, and documentation requirements related to the IPPS | 12.5% | - Major complication/comorbidity (MCC) - Principal diagnosis and medical necessity - Medicare contractors and their impact on CDI - Documentation and medical necessity of setting - Medicare Severity Diagnosis Related Groups (MS-DRGs) - Documentation impact on IPPS reimbursement - Inpatient admission criteria and CMS Two-Midnight Rule - Case mix index (CMI) - Medical staff and clinical staff documentation responsibilities - Coding and billing practices vulnerable to denial - Complication/comorbidity (CC) - IPPS and its updates and revisions |
| Topic 8: Impact of reportable diagnoses on quality of care | 8.33% | - CDI impact on Hospital Value-Based Purchasing - Quality data from record abstraction and claims data - Hospital Readmissions Reduction Program - Healthcare-associated infections and complication codes - Mortality reviews and observed/expected ratios - Hospital-Acquired Condition Reduction Program - 30-day mortality measures - Hospital Value-Based Purchasing - Hospital Inpatient Quality Reporting Program - Documentation and code assignment impact on mortality index - Patient Safety Indicators - Coded data elements affecting Patient Safety Indicators |
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NEW QUESTION # 35
A patient is admitted for UTI with AMS. The physician documents "UTI due to Escherichia coli." CT scan of the head is negative, with AMS improving and family reporting the patient is now at baseline. Admission creatinine is 1.2 mg/dL and sodium is 146 mEq/L. Plan is discharge home today.
The CDI specialist should query for the:
Answer: B
Explanation:
The clinically meaningful documentation gap concerns what condition actually occasioned the inpatient admission and whether the altered mental status represents a defined diagnosis associated with the episode.
The record identifies a UTI due to E. coli, but the patient also presented with AMS significant enough to undergo head CT evaluation. The AMS subsequently resolved to baseline.
A creatinine of 1.2 mg/dL alone does not establish acute kidney injury because AKI requires evidence of an acute change from baseline and appropriate clinical context. Similarly, sodium of 146 mEq/L is only minimally elevated and, without clinical evaluation or treatment demonstrating significance, does not justify a query designed to generate hypernatremia.
Merely clarifying AMS as acute versus chronic is also less useful than determining the actual diagnosis explaining the altered mental state and its relationship to the admission. Depending on provider judgment and supporting evidence, possibilities could include an acute encephalopathic process, delirium, symptoms associated with infection, or another condition.
The query should remain neutral and should not presume that the UTI caused the AMS.
CCDS Reference Topics: Principal diagnosis clarification; AMS; clinical indicators; query prioritization; documentation integrity.
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NEW QUESTION # 36
A patient was admitted with weakness, loss of appetite, hemoglobin 7.8, WBC 2,700, and platelet count 58.
The admitting diagnoses on the history and physical were anemia, leukopenia, decreased platelets, and rule out myelodysplastic syndrome. Based on these clinical indicators a CDI specialist should query for which of the following conditions?
Answer: A
Explanation:
The laboratory findings demonstrate reduction in all three major peripheral blood-cell lines: hemoglobin 7.8 indicates anemia, WBC 2,700 indicates leukopenia, and platelets 58 indicate thrombocytopenia. Collectively, this pattern is consistent with pancytopenia, making option C the most appropriate documentation clarification.
The National Cancer Institute defines pancytopenia as a lower-than-normal number of red blood cells, white blood cells, and platelets. Importantly, pancytopenia describes the hematologic state; it does not establish its underlying etiology. Myelodysplastic syndrome was only being ruled out in the scenario, so the CDI specialist should not infer it as the definitive cause.
Thrombocytopenia alone would capture only one component of the abnormal CBC and would fail to represent the simultaneous anemia and leukopenia. Myelophthisis implies marrow displacement or infiltration and cannot be inferred from these counts alone. Likewise, aplastic anemia is a specific bone-marrow failure diagnosis requiring provider determination and supporting diagnostic evaluation.
A compliant query can present pancytopenia as a clinically supported choice while allowing the provider to document another explanation.
CCDS Reference Topics: Hematology; clinical indicators; medical terminology; compliant query opportunity.
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NEW QUESTION # 37
Which of the following secondary diagnoses has the MOST positive monetary impact on MS-DRG reimbursement?
Answer: C
Explanation:
Among the listed diagnoses, acute diastolic heart failure has the greatest potential MS-DRG impact because ICD-10-CM code I50.31 is classified as an MCC under the FY 2026 CMS MS-DRG system. CMS specifically identifies I50.31 as an MCC, whereas diagnoses classified only as a CC generally produce a lower severity level within DRG families that distinguish no CC/MCC, CC, and MCC cases.
Acute kidney injury, commonly represented by N17.9 when unspecified, is generally a CC rather than an MCC; CMS examples demonstrate N17.9 functioning as a CC in MS-DRG assignment. COPD with acute exacerbation and many delirium diagnoses may also affect severity assignment, but they do not exceed the MCC effect of qualifying acute heart failure in the standard hierarchy represented here.
The wording "monetary impact" must not be interpreted as permission to pursue diagnoses for financial gain.
CDI professionals should query only when clinical indicators justify clarification. Reimbursement is a consequence of accurate documentation and coding, not the clinical justification for creating a diagnosis.
The actual payment impact also depends on the principal diagnosis, existing MCCs, procedures, payer methodology, and final MS-DRG.
CCDS Reference Topics: CC/MCC hierarchy; MS-DRG reimbursement; acute heart failure; compliant CDI practice.
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NEW QUESTION # 38
A patient presents with fever, productive cough, and infiltrates in the right upper lobe per chest x-ray. The history and physical notes that the patient has pneumonia and hypotension. Cultures are drawn and the patient is admitted for IV antibiotics. On day 2, the patient's condition worsens, and the patient is transferred to the ICU for closer monitoring. The ICU physician documents sepsis. Which of the following statements is MOST accurate?
Answer: C
Explanation:
The key issue is whether the sepsis documented on hospital day 2 was present on admission (POA) or developed after admission. The admission already contains potentially relevant indicators-fever, pneumonia, hypotension, cultures, and IV antibiotic treatment-but a CDI specialist cannot independently determine from those indicators that sepsis was POA. Provider clarification is necessary.
This distinction directly affects principal-diagnosis sequencing. When sepsis and a localized infection such as pneumonia are both responsible for admission, the systemic infection is generally sequenced before the localized infection. Conversely, when the patient is admitted with pneumonia and sepsis develops only after admission, pneumonia is sequenced first.
The POA guidelines also emphasize that a diagnosis may not be recognized until days after admission and that delayed documentation does not automatically mean the condition was hospital-acquired. When timing is unclear, querying the provider is appropriate.
There is no evidence supporting aspiration pneumonia, so option B would introduce an unsupported concept.
Options C and D prematurely determine principal diagnosis without resolving the timing of sepsis.
CCDS Reference Topics: Sepsis sequencing; POA assignment; principal diagnosis; compliant clarification of timing.
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NEW QUESTION # 39
A pregnant patient is admitted at 30 weeks' gestation with acute pyelonephritis complicating pregnancy.
Which general sequencing principle applies?
Answer: C
Explanation:
ICD-10-CM Chapter 15 codes generally have sequencing priority over codes from other chapters when a condition complicates pregnancy, childbirth, or the puerperium.
Therefore, when pyelonephritis complicates pregnancy, the appropriate obstetric complication code is generally sequenced first, with additional code(s) used as instructed to identify the specific infection or organism.
This principle is important because ordinary principal-diagnosis logic can be modified by chapter-specific instructions. CDI specialists working with obstetric cases therefore must determine whether the pregnancy affects management and whether the condition is documented as complicating pregnancy.
The only major exception would be when the provider specifically determines that the pregnancy is incidental to the encounter and the applicable coding requirements for incidental pregnancy are met.
A symptom code does not generally supersede an established definitive diagnosis. Likewise, the fact that an infection could occur outside pregnancy does not negate Chapter 15 sequencing when it is complicating the pregnancy.
Correct gestational-age documentation is also important because an additional code may be required to identify the specific week of gestation.
CCDS Reference Topics: Obstetric coding; Chapter 15; sequencing priority; infection in pregnancy; principal diagnosis.
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NEW QUESTION # 40
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