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| Section | Weight | Objectives |
|---|---|---|
| Professionalism, ethics, and compliance | 9.17% | - DRG compliance initiatives - Potential DRG creep - Compliance risks indicated by PEPPER - CDI department goals beyond reimbursement - Medical record confidentiality - Leading queries |
| Healthcare regulations, reimbursement, and documentation requirements related to the IPPS | 12.5% | - Documentation impact on IPPS reimbursement - Coding and billing practices vulnerable to denial - Major complication/comorbidity (MCC) - Documentation and medical necessity of setting - Case mix index (CMI) - Medicare Severity Diagnosis Related Groups (MS-DRGs) - Complication/comorbidity (CC) - IPPS and its updates and revisions - Inpatient admission criteria and CMS Two-Midnight Rule - Principal diagnosis and medical necessity - Medical staff and clinical staff documentation responsibilities - Medicare contractors and their impact on CDI |
| Medical record documentation | 19.17% | - Physician query formats - Types of physician queries - Documentation requiring clarification - Addressing diagnoses without clinical support - ACDIS/AHIMA Guidelines for Achieving a Compliant Query Practice - Provider role and diagnosis code assignment - Health record elements used for diagnosis and procedure code assignment - Situations in which queries are not appropriate - Compliant and noncompliant queries - When a physician query is warranted - Translating clinical indicators into compliant queries - Clinical indicators |
| Official Guidelines for Coding and Reporting | 14.17% | - Official Guidelines for Coding and Reporting updates - Discharge dispositions and transfers - AHA Coding Clinic - Present on admission indicators - Principal diagnosis assignment - Working DRG assignment for multiple diagnoses - Coding guidelines for principal diagnosis selection - Secondary diagnosis assignment - Hospital-acquired conditions |
| Healthcare facility CDI program analysis | 8.33% | - Provider response rates - PEPPER data - Severity of illness and risk of mortality - Physician performance measurement - Hospital-specific financial data - Case mix index (CMI) - CDI program forecasting - CDI specialist productivity metrics - CC/MCC capture - Tracking and trending physician, department, and hospital performance - Basic computer and software application skills - Hospital Value-Based Purchasing measures - High-frequency DRGs - Publicly reported data - Patient Safety Indicators |
| Anatomy and physiology, pathophysiology, pharmacology, and medical terminology | 19.17% | - Diseases and disorders of the hepatobiliary system - Diseases and disorders of the blood and blood-forming organs and immunological disorders - Endocrine, nutritional, and metabolic diseases and disorders - Clinical indicators and query opportunities by Major Diagnostic Category - Diseases and disorders of the digestive system - HIV infections - Diseases and disorders of the circulatory system - Diseases and disorders of the kidney and urinary tract - Diseases and disorders of the musculoskeletal system - Diseases and disorders of the skin, subcutaneous tissue, and breast - Myeloproliferative diseases and disorders and poorly differentiated neoplasms - Diagnostic tests as clinical indicators - Alcohol/drug use and alcohol/drug-induced organic brain disorders - Medications as clinical indicators - Pharmaceuticals and disease processes - Standard medical abbreviations - Mental diseases and disorders - Diseases and disorders of the nervous system - Injuries, poisonings, and toxic effects of drugs - Infectious and parasitic diseases - Diseases and disorders of the respiratory system |
| Communication skills | 9.17% | - Effective and non-confrontational physician communication - Verbal versus written physician communication - Reconciling CDI working DRGs with final coded DRGs - 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 |
| Impact of reportable diagnoses on quality of care | 8.33% | - Hospital Readmissions Reduction Program - Healthcare-associated infections and complication codes - 30-day mortality measures - CDI impact on Hospital Value-Based Purchasing - 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 - Hospital Value-Based Purchasing - Patient Safety Indicators - Hospital-Acquired Condition Reduction Program - Quality data from record abstraction and claims data |
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NEW QUESTION # 77
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: D
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 # 78
A patient presents with crushing substernal chest pain, diaphoresis, ST-segment depression, and a significant rise and fall in cardiac troponin. The cardiologist documents acute coronary syndrome but does not specify the final diagnosis. Which clarification is MOST clinically appropriate?
Answer: D
Explanation:
The clinical picture presents an appropriate opportunity to clarify whether the patient has NSTEMI, unstable angina, or another acute coronary diagnosis.
A significant rise and/or fall in cardiac troponin consistent with acute myocardial injury, together with ischemic symptoms and ECG abnormalities, strongly raises concern for acute myocardial infarction. In contrast, unstable angina generally refers to ischemia without the biomarker evidence required for myocardial infarction.
Nevertheless, CDI should not make the diagnosis independently. Troponin elevations can occur in multiple conditions, including myocarditis, pulmonary embolism, sepsis, tachyarrhythmia, renal disease, and other forms of myocardial injury.
Therefore, the cardiologist should be asked to clarify the final diagnosis based on the complete clinical evaluation.
GERD, chronic stable angina, and old MI do not adequately reflect the acute findings described.
For CCDS preparation, cardiovascular questions frequently require distinguishing symptoms from established diagnoses and understanding the clinical indicators associated with NSTEMI, STEMI, type 2 MI, and other myocardial injury categories.
The ACDIS candidate handbook identifies anatomy, physiology, pharmacology, pathophysiology, and clinical record analysis as essential examination competencies.
CCDS Reference Topics: NSTEMI; acute coronary syndrome; troponin; myocardial ischemia; diagnostic clarification.
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NEW QUESTION # 79
A patient is admitted with a stage 4 pressure ulcer of the right heel. The physician documents the pressure- ulcer diagnosis and location. The wound-care nurse documents stage 4. Which statement is MOST accurate?
Answer: C
Explanation:
Pressure-ulcer staging is one of the recognized circumstances in which ICD-10-CM permits the relevant clinical detail to be obtained from documentation by an appropriate non-provider clinician, such as a qualified wound-care nurse.
The provider establishes the medical diagnosis, while the wound-care clinician's specialized assessment may support the stage assignment. This distinction allows coding to reflect the expertise of clinicians who directly assess the wound without requiring physicians to duplicate every technical staging statement.
Option C is too broad. The exception permitting stage documentation from another clinician does not grant non-provider documentation unrestricted authority to establish all reportable medical diagnoses.
Pressure-ulcer stage is highly relevant because ICD-10-CM pressure-ulcer codes incorporate both anatomical site and stage. It can also have substantial implications for severity reporting, POA assessment, CMS HAC policy, nursing care, quality review, and risk adjustment.
When different clinicians document conflicting stages, clarification should be pursued rather than selecting the most severe value.
CCDS candidates should understand the distinction between provider-established diagnoses and specific coding elements that ICD-10-CM permits to originate from other qualified professionals.
CCDS Reference Topics: Pressure ulcers; wound staging; non-provider documentation; coding exceptions.
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NEW QUESTION # 80
Based on the AHIMA/ACDIS Practice Brief Guidelines for Achieving a Compliant Query Practice, a leading query is one that:
Answer: A
Explanation:
A query becomes problematic when it directs or influences the provider toward a diagnosis that is not supported by the patient's clinical record. Therefore, option C most accurately represents the leading-query concept in this answer set. A compliant query must be based on patient-specific clinical indicators and must preserve the provider's independent clinical judgment.
A multiple-choice query may include a diagnosis not previously documented when that diagnosis is supported by the clinical indicators and when reasonable alternatives are also offered. ACDIS/AHIMA guidance has specifically recognized that presenting a clinically supported new diagnosis among neutral choices does not automatically make the query leading.
Likewise, the timing of a query while a provider is documenting does not make it leading. Cause-and-effect clarification may also be addressed using an appropriate query format when both conditions are documented and the relationship remains uncertain.
The current 2026 ACDIS/AHIMA Guidelines for Achieving a Compliant Query Practice supersede the prior versions and continue to establish compliant provider-query practice as a foundational CDI standard. Queries must be clinically supported, noncoercive, and constructed without reference to reimbursement or other desired outcomes.
CCDS Reference Topics: Leading queries; clinical indicators; compliant query construction; provider independence.
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NEW QUESTION # 81
At discharge, the physician documents, "Possible gram-negative pneumonia." No later documentation rules out the condition. How should the diagnosis generally be handled for an inpatient admission?
Answer: B
Explanation:
In the inpatient hospital setting, an uncertain diagnosis documented at discharge using terminology such as possible, probable, suspected, likely, questionable, compatible with, or consistent with may generally be coded as though the condition existed or was established.
Therefore, "possible gram-negative pneumonia" may be coded in accordance with the inpatient uncertain- diagnosis guideline when it remains the final diagnostic conclusion.
The rationale is that inpatient diagnostic evaluation and treatment frequently occur before absolute confirmation is available, and the patient may have been managed as though the suspected disease were present.
This rule is materially different from outpatient coding, where uncertain diagnoses are generally not coded as established and the documented signs, symptoms, or confirmed conditions are reported instead.
The presence of the uncertain terminology alone does not mandate a query. A query would be appropriate if documentation is contradictory, if the diagnosis is clinically unsupported, or if another documentation issue prevents correct code assignment.
CDI specialists need to recognize this inpatient-specific rule because unnecessary queries for "possible" or
"probable" diagnoses can create physician burden without improving coding accuracy.
CCDS Reference Topics: Uncertain inpatient diagnoses; discharge documentation; pneumonia; inpatient versus outpatient coding.
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NEW QUESTION # 82
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