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| Section | Weight | Objectives |
|---|---|---|
| Topic 1: Impact of reportable diagnoses on quality of care | 8.33% | - Mortality, severity of illness, and risk of mortality - Quality metrics, reporting programs, and financial impact |
| Topic 2: Anatomy and physiology, pathophysiology, pharmacology, and medical terminology | 19.17% | - Anatomy, physiology, pathophysiology, pharmacology, and terminology - Clinical conditions and clinical indicators |
| Topic 3: Official Guidelines for Coding and Reporting | 14.17% | - Coding guidelines, AHA Coding Clinic, HACs, and POA indicators - Principal and secondary diagnosis assignment |
| Topic 4: Medical record documentation | 19.17% | - Documentation clarification and compliant physician queries - Documentation requirements and diagnosis or procedure code assignment |
| Topic 5: Professionalism, ethics, and compliance | 9.17% | - Query compliance, DRG creep, and audit risks - Confidentiality, DRG compliance, and ethical CDI practices |
| Topic 6: Communication skills | 9.17% | - Physician education and effective communication - CDI and coding roles and interdisciplinary collaboration |
| Topic 7: 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 8: Healthcare facility CDI program analysis | 8.33% | - Data analysis, forecasting, and performance measurement - CDI productivity, provider response, CMI, and program metrics |
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NEW QUESTION # 142
A patient is admitted with fever, productive cough, and hypotension. The attending physician documents sepsis due to pneumonia. Acute kidney injury develops and is documented as due to sepsis. Which of the following is the MOST appropriate sequencing concept?
Answer: C
NEW QUESTION # 143
A CDI program reports the following monthly results:
- Provider response rate: 97%
- Provider agreement rate: 84%
- Queries issued after discharge: 38%
- CDI/coder agreement: 96%
Which metric presents the clearest opportunity to improve concurrent CDI workflow?
Answer: C
Explanation:
The 38% post-discharge query rate represents the clearest workflow opportunity because a large proportion of clarification is occurring after the concurrent hospitalization period.
A 97% provider response rate reflects strong physician participation, while a 96% CDI/coder agreement rate indicates substantial alignment between concurrent CDI review and final coding. An 84% agreement rate is not inherently problematic because providers must remain free to disagree with a query based on their clinical judgment.
A high retrospective-query percentage can indicate that cases are being reviewed too late, that certain documentation opportunities are not recognized during hospitalization, that discharge documentation introduces unresolved diagnoses, or that staffing/workflow does not adequately prioritize cases before discharge.
A CDI manager should drill further into the metric by service line, query type, day of stay, weekday/weekend discharge, provider group, and reason for retrospective clarification. This analysis helps distinguish unavoidable retrospective queries from remediable process problems.
The objective is not to eliminate every post-discharge query. Some documentation issues become apparent only after final testing, pathology, procedures, or discharge summaries are completed.
CCDS Reference Topics: CDI program metrics; concurrent versus retrospective review; workflow analysis; performance improvement.
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NEW QUESTION # 144
A patient is admitted with community-acquired pneumonia. On day 3, he begins to show signs of increasing respiratory distress and requires intubation. When he arrives in the ICU, the nurse inserts a urinary catheter and notes that his urine output has decreased. The physician documents respiratory failure and acute renal failure secondary to sepsis caused by pneumonia. The patient's condition would be classified as:
Answer: B
Explanation:
This patient has sepsis with documented acute organ dysfunction, specifically acute respiratory failure and acute renal failure. Under ICD-10-CM coding guidance, sepsis associated with acute organ dysfunction is classified as severe sepsis when the provider establishes the relationship between the systemic infection and the organ dysfunction.
The documentation specifically states that respiratory failure and acute renal failure are secondary to sepsis caused by pneumonia. That causal linkage is critical. FY 2026 Official Guidelines require the underlying systemic infection code, followed by a code from R65.2- for severe sepsis, plus additional codes identifying each associated acute organ dysfunction.
Septic shock is not supported because the scenario does not document circulatory failure attributable to sepsis, persistent hypotension requiring vasopressors, or a provider diagnosis of septic shock. "Septicemia" is also not equivalent terminology for coding sepsis and is not the appropriate classification here.
From a CDI perspective, the defining feature is not simply that the patient is critically ill. It is the documented relationship between sepsis and acute organ dysfunction.
CCDS Reference Topics: Sepsis; severe sepsis; acute organ dysfunction; sequencing guidelines.
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NEW QUESTION # 145
A patient is admitted with a stage 3 sacral pressure ulcer. During hospitalization, the wound deteriorates and is documented as stage 4 at the same site. Which reporting approach is appropriate?
Answer: B
Explanation:
When a pressure ulcer progresses to a higher stage during an inpatient stay, ICD-10-CM instructs reporting that preserves both its stage at admission and the highest stage reached during hospitalization.
Therefore, the stage 3 condition present at admission and subsequent progression to stage 4 must both be represented according to the applicable coding instructions.
This approach accurately portrays both the patient's baseline condition and deterioration after admission.
Reporting only stage 4 would lose important POA information, while reporting only stage 3 would fail to capture the subsequent clinical severity.
An unstageable pressure-ulcer code is not appropriate simply because the wound changed stages.
"Unstageable" has a specific clinical meaning-typically the true depth cannot be determined because the wound base is obscured by slough or eschar or another specified circumstance.
CDI review should ensure documentation includes wound location, stage, laterality when applicable, timing of progression, and relevant wound-care assessment. Qualified wound clinicians may provide pressure-ulcer staging information under applicable non-provider documentation rules.
CCDS Reference Topics: Pressure ulcers; progression; POA; wound staging; quality reporting.
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NEW QUESTION # 146
Under the FY 2026 Hospital-Acquired Condition Reduction Program, which hospitals are subject to the program's payment reduction?
Answer: D
Explanation:
Under the FY 2026 Hospital-Acquired Condition Reduction Program (HACRP), applicable subsection (d) hospitals in the worst-performing quartile based on the Total HAC Score receive a 1% payment reduction on applicable Medicare fee-for-service payments. CMS defines the worst-performing quartile as hospitals whose Total HAC Score is above the 75th percentile.
The FY 2026 program incorporates the CMS Patient Safety and Adverse Events Composite (PSI 90) plus five healthcare-associated infection measures: CLABSI, CAUTI, specified surgical-site infection, MRSA bacteremia, and C. difficile infection.
A single HAC does not automatically trigger the hospital-wide 1% HACRP reduction. Likewise, CMI is not the criterion used to determine HACRP penalties.
It is also important for CCDS candidates to distinguish the HAC Reduction Program from the separate DRA HAC/POA payment provision. CMS explicitly identifies them as distinct programs.
Accurate documentation and coding are important because quality measures rely on reliable clinical data, but CDI activity must remain focused on accurately representing the clinical record rather than manipulating quality metrics.
CCDS Reference Topics: HAC Reduction Program; PSI 90; HAI measures; quality payment; hospital performance.
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NEW QUESTION # 147
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