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| Section | Weight | Objectives |
|---|---|---|
| Communication skills | 9.17% | - Effective and non-confrontational physician communication - Verbal versus written physician communication - Roles and responsibilities of coders working with CDI departments - Reconciling CDI working DRGs with final coded DRGs - Educational presentations for healthcare departments and administration - Physician education forms and tools - Roles and responsibilities of CDI specialists |
| Healthcare regulations, reimbursement, and documentation requirements related to the IPPS | 12.5% | - Principal diagnosis and medical necessity - Medicare contractors and their impact on CDI - Major complication/comorbidity (MCC) - Coding and billing practices vulnerable to denial - Complication/comorbidity (CC) - Medicare Severity Diagnosis Related Groups (MS-DRGs) - Inpatient admission criteria and CMS Two-Midnight Rule - Documentation impact on IPPS reimbursement - Documentation and medical necessity of setting - IPPS and its updates and revisions - Medical staff and clinical staff documentation responsibilities - Case mix index (CMI) |
| Healthcare facility CDI program analysis | 8.33% | - CDI specialist productivity metrics - Provider response rates - Tracking and trending physician, department, and hospital performance - Hospital Value-Based Purchasing measures - Hospital-specific financial data - CDI program forecasting - High-frequency DRGs - Basic computer and software application skills - PEPPER data - Severity of illness and risk of mortality - CC/MCC capture - Patient Safety Indicators - Physician performance measurement - Publicly reported data - Case mix index (CMI) |
| Medical record documentation | 19.17% | - Compliant and noncompliant queries - Situations in which queries are not appropriate - Physician query formats - Provider role and diagnosis code assignment - ACDIS/AHIMA Guidelines for Achieving a Compliant Query Practice - Types of physician queries - Health record elements used for diagnosis and procedure code assignment - Addressing diagnoses without clinical support - When a physician query is warranted - Documentation requiring clarification - Translating clinical indicators into compliant queries - Clinical indicators |
| Professionalism, ethics, and compliance | 9.17% | - Compliance risks indicated by PEPPER - Potential DRG creep - Leading queries - DRG compliance initiatives - CDI department goals beyond reimbursement - Medical record confidentiality |
| Official Guidelines for Coding and Reporting | 14.17% | - Discharge dispositions and transfers - Present on admission indicators - Principal diagnosis assignment - Coding guidelines for principal diagnosis selection - Working DRG assignment for multiple diagnoses - Hospital-acquired conditions - Official Guidelines for Coding and Reporting updates - Secondary diagnosis assignment - AHA Coding Clinic |
| Impact of reportable diagnoses on quality of care | 8.33% | - Coded data elements affecting Patient Safety Indicators - Hospital Value-Based Purchasing - Documentation and code assignment impact on mortality index - Hospital Readmissions Reduction Program - Patient Safety Indicators - Mortality reviews and observed/expected ratios - Hospital Inpatient Quality Reporting Program - 30-day mortality measures - Hospital-Acquired Condition Reduction Program - Quality data from record abstraction and claims data - CDI impact on Hospital Value-Based Purchasing - Healthcare-associated infections and complication codes |
| Anatomy and physiology, pathophysiology, pharmacology, and medical terminology | 19.17% | - Endocrine, nutritional, and metabolic diseases and disorders - Myeloproliferative diseases and disorders and poorly differentiated neoplasms - Diseases and disorders of the kidney and urinary tract - Standard medical abbreviations - Clinical indicators and query opportunities by Major Diagnostic Category - Diseases and disorders of the circulatory system - Mental diseases and disorders - HIV infections - Diseases and disorders of the respiratory system - Infectious and parasitic diseases - Medications as clinical indicators - Diseases and disorders of the hepatobiliary system - Diseases and disorders of the skin, subcutaneous tissue, and breast - Pharmaceuticals and disease processes - Diagnostic tests as clinical indicators - Alcohol/drug use and alcohol/drug-induced organic brain disorders - Diseases and disorders of the blood and blood-forming organs and immunological disorders - Diseases and disorders of the nervous system - Diseases and disorders of the digestive system - Injuries, poisonings, and toxic effects of drugs - Diseases and disorders of the musculoskeletal system |
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NEW QUESTION # 117
A CDI specialist sends a compliant query. The physician answers "other-viral syndrome" and supports the diagnosis in the progress note. The queried diagnosis would have been an MCC. What should the CDI specialist do?
Answer: A
Explanation:
The CDI specialist should accept the physician's clinically supported response. Querying is intended to clarify documentation, not to obtain a predetermined diagnosis or reimbursement result.
A compliant query should preserve the provider's independent clinical judgment. The physician may select one of the offered choices, document another diagnosis, rule out the suspected condition, or state that the diagnosis cannot be determined.
The fact that a different answer would qualify as an MCC is irrelevant to whether the provider's response should be respected.
Repeatedly issuing the same query because the initial response does not increase reimbursement risks creating a coercive or leading process and undermines documentation integrity.
A follow-up query could be justified if materially new clinical information appears or if the response itself remains internally contradictory or incomplete. But disagreement with the financial consequence is not sufficient.
The August 2026 ACDIS/AHIMA guidelines supersede all previous versions and are the current foundational resource for compliant query processes across healthcare settings.
CCDS Reference Topics: Provider autonomy; query response; MCC neutrality; ethical CDI practice; compliant querying.
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NEW QUESTION # 118
A patient's chest x-ray shows pulmonary vascular congestion and pleural effusions. These findings are most consistent with which of the following conditions?
Answer: B
Explanation:
Pulmonary vascular congestion accompanied by pleural effusions is classically associated with congestive heart failure, particularly left-sided or biventricular decompensation. Increased left-sided cardiac filling pressure raises pulmonary venous and capillary hydrostatic pressure, promoting interstitial and alveolar fluid accumulation. Fluid may also migrate into the pleural space, producing unilateral or bilateral pleural effusions.
Additional radiographic indicators of heart failure may include cardiomegaly, cephalization of pulmonary vessels, interstitial edema, Kerley B lines, perihilar alveolar opacities, and bilateral effusions. These findings should always be interpreted alongside symptoms and other clinical evidence such as dyspnea, orthopnea, edema, BNP/NT-proBNP, echocardiography, and response to diuretics.
COPD more commonly demonstrates hyperinflation, flattened diaphragms, and increased lucency rather than pulmonary vascular congestion. Cor pulmonale refers to right-sided cardiac dysfunction resulting from pulmonary disease and does not typically produce the classic pulmonary venous congestion pattern.
Pulmonary embolism may have a normal chest radiograph or nonspecific abnormalities, but pulmonary vascular congestion with effusions is not its characteristic pattern.
For CDI purposes, imaging provides a clinical indicator but does not independently establish the diagnosis or acuity of heart failure.
CCDS Reference Topics: Heart failure pathophysiology; chest radiography; clinical indicators; cardiopulmonary terminology.
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NEW QUESTION # 119
When reviewing a patient's chart in the ICU, a CDI specialist determines a query needs to be placed. As the query is being written, the attending physician is leaving the patient's room after completing rounds. Which of the following is the BEST action to take?
Answer: C
Explanation:
A verbal query is the most efficient and appropriate action because the responsible physician is immediately available and the documentation gap has already been identified. CDI practice is not limited to written or electronic queries; verbal clarification is an accepted communication method when conducted compliantly.
The CDI specialist should present the relevant clinical indicators objectively and ask for clarification without directing the physician toward a preferred diagnosis. The conversation should remain clinically focused and must not mention reimbursement, MS-DRG impact, quality scoring, or other incentives.
Importantly, verbal does not mean informal or undocumented. Current query standards require organizations to maintain an auditable query process. Historically, ACDIS/AHIMA guidance has specifically required the essence of verbal queries to be memorialized, including the reason for clarification and relevant clinical indicators. The 2026 ACDIS/AHIMA Guidelines for Achieving a Compliant Query Practice supersede previous versions and remain the current foundational industry standard for query practice.
Waiting unnecessarily could delay clarification and interfere with concurrent CDI workflow. Since the physician is available, direct professional communication is preferable.
CCDS Reference Topics: Communication skills; verbal queries; concurrent CDI review; compliant query practice.
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NEW QUESTION # 120
A pregnant patient is admitted at 30 weeks' gestation with acute pyelonephritis complicating pregnancy.
Which general sequencing principle applies?
Answer: D
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 # 121
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: A
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 # 122
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