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NEW QUESTION # 132
At discharge, the attending physician documents, "Probable aspiration pneumonia causing the patient's respiratory symptoms." The patient is an inpatient. No subsequent documentation rules out aspiration pneumonia. How should the diagnosis be handled for inpatient coding?
Answer: B
Explanation:
For an inpatient discharge, a diagnosis documented as "probable" may be coded as though the condition existed or was established when it remains documented as such at discharge.
The FY 2026 ICD-10-CM Official Guidelines provide a specific inpatient rule for uncertain diagnoses documented at the time of discharge. Terms such as probable, suspected, likely, questionable, possible, still to be ruled out, compatible with, and consistent with are coded as if the condition existed, because the diagnostic workup and treatment generally correspond to the suspected condition.
Therefore, aspiration pneumonia-not merely the respiratory symptoms-is the appropriate condition to code in this scenario.
This rule is specific to inpatient hospital coding and should not be generalized to outpatient encounters, where uncertain diagnoses are handled differently and symptoms or confirmed conditions are generally reported instead.
A query would still be appropriate if the documentation were contradictory, clinically ambiguous, or if multiple competing diagnoses remained without sufficient clarification. But the word "probable" itself does not create a mandatory inpatient query.
CCDS Reference Topics: Inpatient uncertain diagnoses; aspiration pneumonia; discharge documentation; Official Guidelines.
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NEW QUESTION # 133
Which CMS program can reduce an eligible hospital's Medicare base operating DRG payments by as much as
3% because of excess readmissions?
Answer: C
Explanation:
The Hospital Readmissions Reduction Program (HRRP) reduces payments to applicable hospitals with excess readmissions for specified conditions and procedures. CMS calculates a payment adjustment factor ranging from 1.0 to 0.97, meaning the maximum reduction is 3%.
The adjustment applies to applicable Medicare fee-for-service base operating DRG payments rather than solely to the readmission cases themselves.
This differs from the HAC Reduction Program, which applies a 1% reduction to hospitals in the worst- performing quartile based on defined hospital-acquired-condition measures. Hospital Value-Based Purchasing uses another methodology in which 2% of participating hospitals' base operating DRG payments funds value- based incentive payments.
For CDI professionals, readmission programs demonstrate how clinical documentation can influence more than individual MS-DRG reimbursement. Accurate documentation of comorbidities, principal diagnoses, complications, discharge circumstances, and disease severity contributes to reliable risk-adjusted data.
However, CDI intervention must remain focused on clinical accuracy rather than attempting to alter readmission metrics through unsupported diagnoses.
CCDS Reference Topics: HRRP; readmissions; quality reimbursement; IPPS; risk adjustment.
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NEW QUESTION # 134
A patient is admitted with hypertension and stage 3b chronic kidney disease. The physician does not explicitly state that the CKD is caused by hypertension. The record contains no documentation indicating that the two conditions are unrelated. Which of the following is the MOST appropriate approach when assigning the working diagnoses?
Answer: A
Explanation:
ICD-10-CM presumes a causal relationship between hypertension and chronic kidney disease when both are documented, unless the provider specifically states that the conditions are unrelated. Therefore, the working coding logic should recognize hypertensive CKD and additionally identify the patient's CKD stage.
The FY 2026 Official Guidelines direct assignment of a code from category I12, Hypertensive chronic kidney disease, when hypertension and a condition classified to N18.- are both present. An additional N18.- code is required to identify the CKD stage. In this case, the documented stage is 3b.
A provider query solely to establish the hypertension-CKD relationship is unnecessary because ICD-10-CM itself supplies the presumed relationship. However, a query could become necessary if the physician explicitly states or strongly suggests that the CKD is unrelated to hypertension or if conflicting documentation exists.
The CDI specialist must distinguish coding conventions that automatically establish certain relationships from situations in which provider linkage is mandatory. This prevents unnecessary queries and supports accurate working-DRG assignment.
CCDS Reference Topics: Hypertensive CKD; presumed causal relationships; CKD staging; coding conventions; working MS-DRG.
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NEW QUESTION # 135
Documentation indicates an excisional debridement was performed without further specification. The CDI specialist should query to clarify which of the following?
Answer: C
Explanation:
The most critical missing element is the depth or level of tissue actually debrided. Documentation of an excisional debridement should identify whether tissue removed included skin, subcutaneous tissue, fascia, muscle, bone, or another anatomical layer. The level removed is fundamental to accurate procedural classification and coding.
CMS wound-care documentation standards similarly emphasize that the medical record should describe the type and depth of tissue removed. Merely knowing that an excisional debridement occurred does not establish the anatomical level of the procedure.
The instrument may provide useful procedural context-for example, scalpel, scissors, curette, or other technique-but the instrument alone does not identify the deepest tissue excised. Wound size can be important for clinical care and certain coding systems, but it does not replace documentation of the tissue level removed. The identity of the person performing the procedure is also part of procedural documentation but does not answer the principal coding-specific deficiency in this scenario.
A CDI query should therefore seek the deepest tissue level actually excised rather than infer it from the wound's overall depth.
CCDS Reference Topics: Medical record documentation; ICD-10-PCS/procedure documentation; debridement specificity.
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NEW QUESTION # 136
A patient with an indwelling central venous catheter develops fever and positive blood cultures for Staphylococcus aureus. The physician documents "bacteremia" but does not establish whether the catheter caused the infection. Which action is MOST appropriate?
Answer: C
Explanation:
The record supports a cause-and-effect clarification query. The presence of an indwelling central line together with bacteremia does not automatically establish a catheter-related bloodstream infection or device complication.
The provider must determine whether the infection is related to the catheter, another source, or an undetermined cause when the classification requires clinical linkage. CDI should present the catheter history, onset of fever, culture results, line assessment, treatment, line removal or exchange if applicable, and other relevant findings without directing the provider toward a device-related complication.
A positive blood culture likewise does not independently establish sepsis. Bacteremia and sepsis are distinct concepts; the provider must make the systemic infection diagnosis using the entire clinical picture.
Automatically assigning a complication merely because a device is present risks inaccurate reporting of healthcare-associated complications and may affect quality metrics, reimbursement, and public data.
Current ACDIS/AHIMA guidance emphasizes that queries should arise from patient-specific clinical information and preserve provider clinical judgment rather than presuming causal relationships.
CCDS Reference Topics: Device-related infections; cause-and-effect relationships; bacteremia; clinical indicators; compliant query construction.
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NEW QUESTION # 137
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