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| Section | Weight | Objectives |
|---|---|---|
| Topic 1: Medical record documentation | 19.17% | - Documentation requirements and diagnosis or procedure code assignment - Documentation clarification and compliant physician queries |
| Topic 2: Official Guidelines for Coding and Reporting | 14.17% | - Coding guidelines, AHA Coding Clinic, HACs, and POA indicators - Principal and secondary diagnosis assignment |
| Topic 3: Anatomy and physiology, pathophysiology, pharmacology, and medical terminology | 19.17% | - Anatomy, physiology, pathophysiology, pharmacology, and terminology - Clinical conditions and clinical indicators |
| Topic 4: Professionalism, ethics, and compliance | 9.17% | - Query compliance, DRG creep, and audit risks - Confidentiality, DRG compliance, and ethical CDI practices |
| Topic 5: Healthcare regulations, reimbursement, and documentation requirements related to the IPPS | 12.5% | - IPPS, MS-DRGs, reimbursement, and medical necessity - CC/MCC, CMI, Medicare contractors, and compliance |
| Topic 6: Impact of reportable diagnoses on quality of care | 8.33% | - Quality metrics, reporting programs, and financial impact - Mortality, severity of illness, and risk of mortality |
| Topic 7: Communication skills | 9.17% | - CDI and coding roles and interdisciplinary collaboration - Physician education and effective communication |
| Topic 8: Healthcare facility CDI program analysis | 8.33% | - CDI productivity, provider response, CMI, and program metrics - Data analysis, forecasting, and performance measurement |
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NEW QUESTION # 108
Which pressure-ulcer category is specifically included in the traditional CMS HAC payment policy when the condition is not present on admission?
Answer: B
Explanation:
CMS's Hospital-Acquired Condition payment framework specifically identifies Stage III and Stage IV pressure ulcers among the defined HAC categories when applicable conditions are not present on admission.
The distinction is important because not every pressure injury automatically triggers HAC payment treatment.
Stage and POA status therefore require accurate documentation.
A hospital-acquired pressure ulcer remains reportable even when HAC payment provisions apply. CMS does not instruct hospitals to suppress or omit such conditions. Instead, defined HAC diagnoses that are not POA may lose the CC/MCC payment effect they otherwise would contribute to the MS-DRG, subject to applicable grouper rules.
The CDI specialist should ensure that wound location, laterality when relevant, stage, progression, and timing are accurately documented. Qualified wound-care nurse documentation may be used for pressure-ulcer staging under the ICD-10-CM non-provider documentation exception, while the diagnosis itself remains subject to provider-documentation requirements.
CDI professionals must also distinguish the HAC/POA MS-DRG payment provision from the separate HAC Reduction Program, which reduces applicable hospital payments by 1% for hospitals in the worst-performing quartile.
CCDS Reference Topics: HACs; pressure ulcers; POA; MS-DRG adjustment; wound documentation.
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NEW QUESTION # 109
A patient is admitted with a documented diagnosis of acute hypoxic respiratory failure. Which of the following clinical data BEST supports the diagnosis?
Answer: B
Explanation:
Option A provides the strongest clinical support for acute hypoxic respiratory failure because it demonstrates substantial respiratory distress and progressive need for oxygen/ventilatory support. Tripod positioning is an objective sign of increased work of breathing. Escalation to a non-rebreather mask indicates a substantial oxygen requirement, and subsequent endotracheal intubation demonstrates failure of less invasive respiratory support.
Acute respiratory failure is ultimately a provider diagnosis, and no single oxygen-saturation threshold establishes it in every patient. A CDI specialist therefore evaluates the entire clinical picture: oxygenation, baseline respiratory status, work of breathing, arterial blood gases when available, escalating oxygen requirements, ventilatory support, and treatment intensity.
An SaO# of 91% on low-flow oxygen may represent clinically important hypoxemia, but without additional evidence it is less compelling than the severe respiratory compromise described in option A. Likewise, a patient with COPD who chronically uses 2 L/min oxygen and maintains an SaO# of 94% may simply be at baseline.
FY 2026 ICD-10-CM guidance recognizes acute respiratory failure as a reportable diagnosis and permits it as principal or secondary depending on the circumstances of admission.
CCDS Reference Topics: Respiratory failure; clinical indicators; pathophysiology; clinical validation.
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NEW QUESTION # 110
A patient has a history of a type 2 MI 30 days ago. The patient is admitted for chest pain which is determined to be an NSTEMI. Which of the following diagnosis(es) should be coded to identify the working MS-DRG?
Answer: A
Explanation:
The current NSTEMI is the acute condition driving the admission. The prior type 2 myocardial infarction occurred 30 days earlier, placing it beyond the ICD-10-CM four-week acute-MI reporting window. The Official Guidelines state that category I21 codes may continue to be reported while an MI is four weeks old or less; after that period, an aftercare code may be appropriate when continued MI-related care is being provided, or I25.2 may describe an old/healed MI when applicable.
There is an additional reason not to select a "subsequent MI" answer. Category I22 is restricted to qualifying subsequent type 1 or unspecified acute myocardial infarctions occurring within four weeks of the initial qualifying MI. Type 2 MI is classified to I21.A1 rather than I22.
Therefore, the previous type 2 MI does not support selection of a subsequent-MI option in this 30-day scenario. The active NSTEMI is the diagnosis relevant to the working MS-DRG. "Initial encounter" in answer B is exam terminology rather than an ICD-10-CM seventh-character designation for MI, but B is clearly the intended correct choice.
CCDS Reference Topics: Official Guidelines-acute myocardial infarction; working MS-DRG; circulatory disorders.
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NEW QUESTION # 111
A wound care nurse documents an assessment and care of a pressure ulcer. For coding purposes, the wound care nurse's documentation can be used to assign which of the following?
Answer: C
Explanation:
The wound care nurse's documentation may be used to establish the stage of a pressure ulcer, making option D correct. ICD-10-CM provides specific exceptions to the general rule that diagnosis code assignment is based on documentation by a provider legally accountable for establishing diagnoses. Pressure-ulcer staging is one of the clinical details that may be derived from documentation by qualified non-provider clinicians involved in the patient's care.
Wound care nurses possess specialized expertise in pressure-injury assessment and commonly document staging based on tissue involvement. Current ICD-10-CM guidance directs assignment of the pressure-ulcer stage according to clinical documentation and provides specific rules for unstageable ulcers, healing ulcers, and ulcers that progress during hospitalization.
This exception does not mean that a wound-care nurse independently establishes every element of the medical diagnosis for coding purposes. The provider documentation remains central to identifying the pressure-ulcer diagnosis and relevant clinical condition, while the stage may come from qualified clinician documentation.
POA assignment follows separate reporting rules and is based on whether the condition was present at the time inpatient admission occurred.
CCDS Reference Topics: Pressure ulcers; non-provider documentation; staging; coding conventions.
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NEW QUESTION # 112
An MS-DRG family is divided into three severity levels: with MCC, with CC, and without CC/MCC.
Assuming all other grouper conditions are identical, which secondary diagnosis category generally results in the highest severity-level assignment?
Answer: A
Explanation:
An MCC-major complication or comorbidity-represents the highest secondary-diagnosis severity category within the standard three-tier MS-DRG hierarchy. CMS describes MCCs as diagnoses with the highest level of severity affecting hospital resource use, CCs as conditions with a moderate level, and non-CC diagnoses as the lowest severity level.
When an MS-DRG family is divided into "with MCC," "with CC," and "without CC/MCC," the presence of a qualifying MCC generally moves the case into the highest severity subdivision, assuming no exclusion or other grouper rule prevents that effect.
This does not mean every MCC always increases payment. Some secondary diagnoses are excluded as MCCs or CCs in particular circumstances because of principal-diagnosis exclusions or DRG-specific logic. CMS's FY 2026 Definitions Manual specifically contains exclusion lists and severity logic for such situations.
CDI specialists should understand MCC/CC logic to interpret working DRGs, but query activity must be driven by clinical accuracy rather than the financial value of a severity level.
CCDS Reference Topics: MS-DRGs; MCC; CC; severity subdivisions; resource utilization; reimbursement compliance.
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NEW QUESTION # 113
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