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| Section | Weight | Objectives |
|---|---|---|
| Impact of reportable diagnoses on quality of care | 8.33% | - Hospital Value-Based Purchasing - Patient Safety Indicators - 30-day mortality measures - Hospital-Acquired Condition Reduction Program - Coded data elements affecting Patient Safety Indicators - Hospital Inpatient Quality Reporting Program - Mortality reviews and observed/expected ratios - Documentation and code assignment impact on mortality index - CDI impact on Hospital Value-Based Purchasing - Quality data from record abstraction and claims data - Healthcare-associated infections and complication codes - Hospital Readmissions Reduction Program |
| Professionalism, ethics, and compliance | 9.17% | - DRG compliance initiatives - CDI department goals beyond reimbursement - Leading queries - Compliance risks indicated by PEPPER - Potential DRG creep - Medical record confidentiality |
| Official Guidelines for Coding and Reporting | 14.17% | - AHA Coding Clinic - Official Guidelines for Coding and Reporting updates - Present on admission indicators - Principal diagnosis assignment - Secondary diagnosis assignment - Discharge dispositions and transfers - Hospital-acquired conditions - Coding guidelines for principal diagnosis selection - Working DRG assignment for multiple diagnoses |
| Medical record documentation | 19.17% | - Addressing diagnoses without clinical support - Physician query formats - Documentation requiring clarification - When a physician query is warranted - Clinical indicators - Provider role and diagnosis code assignment - ACDIS/AHIMA Guidelines for Achieving a Compliant Query Practice - Health record elements used for diagnosis and procedure code assignment - Situations in which queries are not appropriate - Compliant and noncompliant queries - Types of physician queries - Translating clinical indicators into compliant queries |
| Healthcare regulations, reimbursement, and documentation requirements related to the IPPS | 12.5% | - Coding and billing practices vulnerable to denial - Medicare Severity Diagnosis Related Groups (MS-DRGs) - Medicare contractors and their impact on CDI - Case mix index (CMI) - IPPS and its updates and revisions - Medical staff and clinical staff documentation responsibilities - Inpatient admission criteria and CMS Two-Midnight Rule - Documentation impact on IPPS reimbursement - Major complication/comorbidity (MCC) - Documentation and medical necessity of setting - Principal diagnosis and medical necessity - Complication/comorbidity (CC) |
| Communication skills | 9.17% | - Educational presentations for healthcare departments and administration - Reconciling CDI working DRGs with final coded DRGs - Physician education forms and tools - Roles and responsibilities of coders working with CDI departments - Verbal versus written physician communication - Effective and non-confrontational physician communication - Roles and responsibilities of CDI specialists |
| Healthcare facility CDI program analysis | 8.33% | - Physician performance measurement - High-frequency DRGs - Patient Safety Indicators - CC/MCC capture - PEPPER data - Provider response rates - Hospital Value-Based Purchasing measures - CDI program forecasting - Case mix index (CMI) - Tracking and trending physician, department, and hospital performance - Publicly reported data - Basic computer and software application skills - Hospital-specific financial data - Severity of illness and risk of mortality - CDI specialist productivity metrics |
| Anatomy and physiology, pathophysiology, pharmacology, and medical terminology | 19.17% | - Diseases and disorders of the musculoskeletal system - Diseases and disorders of the digestive system - Myeloproliferative diseases and disorders and poorly differentiated neoplasms - Pharmaceuticals and disease processes - Diseases and disorders of the kidney and urinary tract - Injuries, poisonings, and toxic effects of drugs - Diagnostic tests as clinical indicators - Medications as clinical indicators - Standard medical abbreviations - Diseases and disorders of the respiratory system - Infectious and parasitic diseases - Endocrine, nutritional, and metabolic diseases and disorders - Diseases and disorders of the nervous system - Clinical indicators and query opportunities by Major Diagnostic Category - HIV infections - Diseases and disorders of the hepatobiliary system - Diseases and disorders of the circulatory system - Mental diseases and disorders - Diseases and disorders of the blood and blood-forming organs and immunological disorders - Diseases and disorders of the skin, subcutaneous tissue, and breast - Alcohol/drug use and alcohol/drug-induced organic brain disorders |
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NEW QUESTION # 89
Hospital A is developing a query policy. Open-ended queries will be encouraged. The provider is expected to document on the query form, which will be retained as part of the health record. Hospital A will remove any unanswered queries and shred them to avoid any incomplete forms within the health record. Which of the following is considered a high-risk query practice?
Answer: B
Explanation:
The high-risk practice is destroying unanswered queries. Query retention should be governed by an established organizational policy and should not depend on whether the provider answers the query.
Selectively destroying unanswered queries can create significant compliance, audit, and record-integrity concerns because it removes evidence of the documentation-clarification process.
ACDIS/AHIMA guidance has consistently required organizations to establish query-retention policies.
Queries may be retained as part of the permanent health record or maintained as a retrievable business record according to organizational policy and legal requirements. The current 2026 ACDIS/AHIMA query practice guidance supersedes all previous editions, reinforcing the importance of a standardized, defensible query process.
Keeping queries in the health record is not inherently problematic when policy defines them as part of that record. Likewise, a new diagnosis may be included in a multiple-choice query when it is supported by patient- specific clinical indicators and the choices remain nonleading. A yes/no query can also be compliant in defined circumstances, such as clarification of a diagnosis or relationship already documented.
Selective destruction is therefore the clear compliance risk.
CCDS Reference Topics: Query retention; compliance; organizational query policy; audit integrity.
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NEW QUESTION # 90
A patient is admitted with right-sided weakness and aphasia. MRI confirms an acute left cerebral infarction.
Two days later, aphasia resolves but right-sided weakness remains. The physician's documentation continues to state "TIA." What should the CDI specialist do?
Answer: A
Explanation:
The record contains a significant clinical-documentation discrepancy. A TIA is characterized by transient neurologic dysfunction without acute infarction, whereas this patient's MRI demonstrates an acute cerebral infarction and the patient continues to have a persistent focal neurologic deficit.
Therefore, the provider should be asked to clarify the final diagnosis.
The CDI specialist cannot independently replace TIA with cerebral infarction, even though the clinical findings strongly favor an infarction. Provider documentation must reconcile the diagnostic evidence.
Automatically reporting both conditions could also misrepresent the encounter when one diagnosis has effectively been superseded by subsequent findings.
The query should objectively present the initial TIA documentation, MRI-confirmed infarction, persistent right-sided weakness, and resolution of aphasia, then ask the physician to clarify the final neurologic diagnosis.
This scenario illustrates why concurrent CDI review must continue beyond initial admission documentation.
Early diagnoses may evolve as diagnostic testing becomes available.
Accurate stroke documentation affects principal diagnosis, severity representation, rehabilitation planning, risk adjustment, quality reporting, and longitudinal patient history.
CCDS Reference Topics: Cerebral infarction; TIA; imaging; conflicting documentation; diagnostic evolution.
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NEW QUESTION # 91
A CDI program is piloting a new query form to better capture the documentation of pneumonia specificity.
Which of the following would be the BEST indicator to determine the effectiveness of the query form?
Answer: C
Explanation:
The most meaningful indicator is an increased volume of appropriately supported cases grouping to respiratory infection DRGs. The stated purpose of the pilot is not merely to obtain more physician responses; it is specifically to improve documentation of the type or etiology of pneumonia.
When providers document clinically supported pneumonia specificity-for example, an identified bacterial etiology or another qualifying respiratory infection-the coded case may move from a less specific/simple pneumonia grouping into a respiratory infections and inflammations DRG family, depending on the final diagnoses and grouper logic. A trend toward the expected DRG distribution can therefore demonstrate that the form is accomplishing its documentation objective.
Provider response and agreement rates are valuable CDI process metrics, but neither proves that useful specificity was obtained. A physician could respond to every query without adding meaningful diagnostic detail. Likewise, an increase in simple pneumonia DRGs would suggest that the intended specificity is not being captured effectively.
A robust CDI analysis should also verify that any DRG shift reflects clinically valid documentation rather than query pressure or reimbursement-oriented behavior.
CCDS Reference Topics: CDI metrics; query effectiveness; pneumonia specificity; MS-DRG trend analysis.
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NEW QUESTION # 92
Which statement BEST defines the principal diagnosis for an inpatient hospitalization?
Answer: C
Explanation:
The principal diagnosis is the condition established after study to be chiefly responsible for occasioning the patient's admission to the hospital for care. This is the UHDDS definition used in the ICD-10-CM Official Guidelines for inpatient principal-diagnosis selection.
"After study" is critical. The diagnosis initially suspected in the emergency department may change after diagnostic testing, consultation, treatment response, surgery, pathology, or other evaluation. The final principal diagnosis therefore may differ from the first diagnosis documented.
Relative weight does not determine principal diagnosis. A hospital cannot select a higher-paying condition merely because it produces a more favorable MS-DRG. Similarly, medication volume is not a principal- diagnosis criterion.
For CDI specialists, principal-diagnosis review requires understanding the circumstances surrounding admission, the diagnostic workup, final provider documentation, sequencing conventions, and any chapter- specific guidelines. When two conditions are documented and it is unclear which chiefly occasioned the admission, a provider query may be warranted.
The CCDS content outline specifically tests the principles and application of principal-diagnosis assignment.
CCDS Reference Topics: Principal diagnosis; UHDDS; inpatient sequencing; working MS-DRG.
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NEW QUESTION # 93
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: A
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 # 94
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