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| Section | Weight | Objectives |
|---|---|---|
| Topic 1: Impact of reportable diagnoses on quality of care | 8.33% | - Quality data from record abstraction and claims data - Coded data elements affecting Patient Safety Indicators - Mortality reviews and observed/expected ratios - CDI impact on Hospital Value-Based Purchasing - Hospital-Acquired Condition Reduction Program - Healthcare-associated infections and complication codes - Hospital Inpatient Quality Reporting Program - Hospital Value-Based Purchasing - Hospital Readmissions Reduction Program - Patient Safety Indicators - 30-day mortality measures - Documentation and code assignment impact on mortality index |
| Topic 2: Anatomy and physiology, pathophysiology, pharmacology, and medical terminology | 19.17% | - Diseases and disorders of the blood and blood-forming organs and immunological disorders - Clinical indicators and query opportunities by Major Diagnostic Category - Infectious and parasitic diseases - Diagnostic tests as clinical indicators - Diseases and disorders of the digestive system - HIV infections - Mental diseases and disorders - Diseases and disorders of the circulatory system - Diseases and disorders of the respiratory system - Diseases and disorders of the nervous system - Diseases and disorders of the hepatobiliary system - Injuries, poisonings, and toxic effects of drugs - Pharmaceuticals and disease processes - Alcohol/drug use and alcohol/drug-induced organic brain disorders - Myeloproliferative diseases and disorders and poorly differentiated neoplasms - Diseases and disorders of the kidney and urinary tract - Standard medical abbreviations - Diseases and disorders of the musculoskeletal system - Diseases and disorders of the skin, subcutaneous tissue, and breast - Endocrine, nutritional, and metabolic diseases and disorders - Medications as clinical indicators |
| Topic 3: Medical record documentation | 19.17% | - Addressing diagnoses without clinical support - Compliant and noncompliant queries - Types of physician queries - Situations in which queries are not appropriate - When a physician query is warranted - Physician query formats - ACDIS/AHIMA Guidelines for Achieving a Compliant Query Practice - Documentation requiring clarification - Provider role and diagnosis code assignment - Translating clinical indicators into compliant queries - Clinical indicators - Health record elements used for diagnosis and procedure code assignment |
| Topic 4: Healthcare facility CDI program analysis | 8.33% | - High-frequency DRGs - Hospital-specific financial data - Physician performance measurement - Severity of illness and risk of mortality - Hospital Value-Based Purchasing measures - CDI program forecasting - Tracking and trending physician, department, and hospital performance - Basic computer and software application skills - Provider response rates - CDI specialist productivity metrics - Patient Safety Indicators - Publicly reported data - PEPPER data - Case mix index (CMI) - CC/MCC capture |
| Topic 5: Communication skills | 9.17% | - Verbal versus written physician communication - Roles and responsibilities of coders working with CDI departments - Effective and non-confrontational physician communication - Physician education forms and tools - Educational presentations for healthcare departments and administration - Reconciling CDI working DRGs with final coded DRGs - Roles and responsibilities of CDI specialists |
| Topic 6: Healthcare regulations, reimbursement, and documentation requirements related to the IPPS | 12.5% | - IPPS and its updates and revisions - Major complication/comorbidity (MCC) - Documentation and medical necessity of setting - Inpatient admission criteria and CMS Two-Midnight Rule - Coding and billing practices vulnerable to denial - Medicare contractors and their impact on CDI - Principal diagnosis and medical necessity - Medicare Severity Diagnosis Related Groups (MS-DRGs) - Documentation impact on IPPS reimbursement - Case mix index (CMI) - Medical staff and clinical staff documentation responsibilities - Complication/comorbidity (CC) |
| Topic 7: Official Guidelines for Coding and Reporting | 14.17% | - Official Guidelines for Coding and Reporting updates - AHA Coding Clinic - Secondary diagnosis assignment - Discharge dispositions and transfers - Coding guidelines for principal diagnosis selection - Present on admission indicators - Working DRG assignment for multiple diagnoses - Hospital-acquired conditions - Principal diagnosis assignment |
| Topic 8: Professionalism, ethics, and compliance | 9.17% | - CDI department goals beyond reimbursement - Compliance risks indicated by PEPPER - DRG compliance initiatives - Leading queries - Medical record confidentiality - Potential DRG creep |
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NEW QUESTION # 63
A patient's past medical history lists remote peptic ulcer disease. During the current admission, the condition receives no evaluation, treatment, diagnostic workup, extended length of stay, or increased nursing monitoring. Which statement is MOST accurate?
Answer: C
Explanation:
The remote peptic ulcer disease generally does not meet the definition of a reportable secondary diagnosis for this hospitalization because it does not affect current patient care.
For inpatient reporting, additional diagnoses include clinically significant conditions that coexist at admission or develop subsequently and affect care through factors such as clinical evaluation, therapeutic treatment, diagnostic procedures, extended length of stay, or increased nursing care and monitoring.
Merely appearing in a past medical history or problem list does not make a condition reportable. The condition must satisfy applicable secondary-diagnosis criteria or another specific coding instruction.
This principle prevents the coded record from becoming populated with historical conditions having no relevance to the current hospitalization. It also underscores why CDI review should focus on diagnoses that meaningfully characterize the current episode of care.
Whether a diagnosis is classified as a CC or MCC is a separate MS-DRG concept. A diagnosis must first be appropriately reportable before its severity classification becomes relevant.
The CCDS outline specifically requires application of both principal- and secondary-diagnosis reporting principles.
CCDS Reference Topics: Additional diagnoses; clinically significant secondary conditions; historical diagnoses; resource utilization.
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NEW QUESTION # 64
A pregnant female presents to the ED with diarrhea, cramps, nausea, and vomiting for the past 12 hours. She was admitted with enteritis due to Clostridium difficile and provided IV fluids. Which of the following coding guidelines applies to determining the principal diagnosis for this patient?
Answer: C
Explanation:
For a pregnant patient, the first coding consideration is the Chapter 15 obstetric guideline unless the provider explicitly documents that the pregnancy is incidental to the encounter. ICD-10-CM codes from O00-O9A have sequencing priority over codes from other chapters when a condition complicates pregnancy, childbirth, or the puerperium.
Therefore, although the patient's underlying clinical disease is Clostridium difficile enteritis, the principal- diagnosis analysis begins with the applicable pregnancy-complication code. An additional infectious-disease code would then be used as appropriate to identify the specific infection. The infectious and parasitic disease chapter does not override the obstetric sequencing rules.
Signs such as diarrhea, cramps, nausea, and vomiting are also not the principal coding focus once a definitive diagnosis-C. difficile enteritis-has been established. Similarly, an etiology/manifestation sequencing convention is not the controlling rule in this scenario.
The critical CCDS concept is recognition of chapter-specific sequencing rules. A CDI specialist reviewing pregnant patients must recognize that otherwise standard principal-diagnosis logic may be superseded by obstetric instructions.
CCDS Reference Topics: Official Guidelines for Coding and Reporting-Chapter 15; principal diagnosis selection; chapter-specific sequencing.
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NEW QUESTION # 65
A CDI specialist submits a neutral query regarding possible acute blood loss anemia. The physician answers
"clinically unable to determine." The CDI specialist believes documenting the diagnosis would increase reimbursement substantially. What is the MOST appropriate next action?
Answer: D
Explanation:
The provider's response should be respected unless new information or a genuine unresolved documentation issue creates a legitimate reason for additional clarification.
"Clinically unable to determine" is an acceptable professional conclusion when the available evidence does not permit the provider to confidently establish a diagnosis. A CDI specialist must not continue sending essentially the same query simply because a different response would produce more favorable reimbursement.
Likewise, CDI cannot alter the provider's response or instruct coding personnel to assign a diagnosis that the provider declined to establish.
The 2026 ACDIS/AHIMA Guidelines for Achieving a Compliant Query Practice supersede all previous versions and serve as the current foundational resource for query processes. The query process is intended to improve the accuracy, completeness, and integrity of documentation-not to secure a predetermined financial result.
A legitimate follow-up could occur if new laboratory values, operative findings, transfusion information, pathology, or other material information emerges after the original response and creates a materially different clarification question.
Professional CDI practice requires balancing clinical advocacy with provider autonomy, ethical conduct, and regulatory compliance.
CCDS Reference Topics: Provider query responses; ethical CDI practice; repeated queries; provider independence; compliance.
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NEW QUESTION # 66
A patient with sepsis has acute confusion, impaired attention, fluctuating mental status, and no focal neurologic findings. CT of the head is negative. The provider documents only "AMS secondary to infection." Which clarification would be MOST clinically appropriate?
Answer: B
Explanation:
The documented acute mental-status change associated with systemic infection creates a reasonable clarification opportunity for acute metabolic encephalopathy, assuming the complete clinical record supports that diagnosis.
Encephalopathy represents diffuse cerebral dysfunction arising from systemic, metabolic, toxic, hypoxic, infectious, or other causes. Acute confusion, impaired attention, fluctuating cognition, and absence of a focal lesion can support an encephalopathic process.
However, the CDI specialist cannot convert "altered mental status" into encephalopathy independently. The provider must determine whether the patient's presentation represents metabolic encephalopathy, delirium, medication effect, dementia, another neurologic condition, or simply a nonspecific symptom.
Chronic dementia does not fit the acute fluctuating pattern unless underlying dementia is separately documented. Cerebral infarction would generally require compatible focal neurologic findings and clinical or imaging evidence. Transient global amnesia typically presents with prominent acute memory disturbance rather than generalized encephalopathy.
A compliant query should include the mental-status findings, infectious process, relevant laboratory data, neurologic evaluation, treatment, and clinical course.
CCDS Reference Topics: Encephalopathy; altered mental status; infection; neurologic clinical indicators; diagnostic clarification.
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NEW QUESTION # 67
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: B
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 # 68
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