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| Section | Weight | Objectives |
|---|---|---|
| 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 |
| Healthcare facility CDI program analysis | 8.33% | - CDI productivity, provider response, CMI, and program metrics - Data analysis, forecasting, and performance measurement |
| Professionalism, ethics, and compliance | 9.17% | - Query compliance, DRG creep, and audit risks - Confidentiality, DRG compliance, and ethical CDI practices |
| Anatomy and physiology, pathophysiology, pharmacology, and medical terminology | 19.17% | - Anatomy, physiology, pathophysiology, pharmacology, and terminology - Clinical conditions and clinical indicators |
| Official Guidelines for Coding and Reporting | 14.17% | - Principal and secondary diagnosis assignment - Coding guidelines, AHA Coding Clinic, HACs, and POA indicators |
| Communication skills | 9.17% | - Physician education and effective communication - CDI and coding roles and interdisciplinary collaboration |
| Medical record documentation | 19.17% | - Documentation requirements and diagnosis or procedure code assignment - Documentation clarification and compliant physician queries |
| 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 |
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NEW QUESTION # 57
A patient was admitted with weakness, loss of appetite, hemoglobin 7.8, WBC 2,700, and platelet count 58.
The admitting diagnoses on the history and physical were anemia, leukopenia, decreased platelets, and rule out myelodysplastic syndrome. Based on these clinical indicators a CDI specialist should query for which of the following conditions?
Answer: C
Explanation:
The laboratory findings demonstrate reduction in all three major peripheral blood-cell lines: hemoglobin 7.8 indicates anemia, WBC 2,700 indicates leukopenia, and platelets 58 indicate thrombocytopenia. Collectively, this pattern is consistent with pancytopenia, making option C the most appropriate documentation clarification.
The National Cancer Institute defines pancytopenia as a lower-than-normal number of red blood cells, white blood cells, and platelets. Importantly, pancytopenia describes the hematologic state; it does not establish its underlying etiology. Myelodysplastic syndrome was only being ruled out in the scenario, so the CDI specialist should not infer it as the definitive cause.
Thrombocytopenia alone would capture only one component of the abnormal CBC and would fail to represent the simultaneous anemia and leukopenia. Myelophthisis implies marrow displacement or infiltration and cannot be inferred from these counts alone. Likewise, aplastic anemia is a specific bone-marrow failure diagnosis requiring provider determination and supporting diagnostic evaluation.
A compliant query can present pancytopenia as a clinically supported choice while allowing the provider to document another explanation.
CCDS Reference Topics: Hematology; clinical indicators; medical terminology; compliant query opportunity.
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NEW QUESTION # 58
A patient is admitted with pneumonia. On hospital day 3, the patient deteriorates and the physician documents that sepsis developed after admission as a consequence of the pneumonia. Which diagnosis is generally sequenced first?
Answer: B
Explanation:
When a patient is admitted with a localized infection and sepsis develops after admission, the localized infection is generally sequenced as the principal diagnosis, followed by the appropriate sepsis code.
The FY 2026 ICD-10-CM Official Guidelines explicitly distinguish this circumstance from cases in which both the localized infection and sepsis are present on admission. When sepsis develops only after admission, the localized infection responsible for the original hospitalization remains principal.
Therefore, pneumonia is sequenced first in this scenario.
If the patient subsequently develops acute organ dysfunction related to sepsis and the provider documents severe sepsis, additional severe-sepsis and organ-dysfunction codes are assigned as appropriate. The severe- sepsis code cannot itself serve as principal diagnosis.
This question demonstrates why CDI specialists must clarify timing. Simply seeing both "pneumonia" and
"sepsis" in a discharge summary is insufficient to determine correct sequencing when the onset relationship is unclear.
The POA status of sepsis also becomes relevant because documentation indicates that it developed after inpatient admission.
CCDS Reference Topics: Sepsis; pneumonia; sequencing; timing; POA; principal diagnosis.
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NEW QUESTION # 59
Which of the following is considered by CMS to be a HAC requiring MS-DRG adjustment if not POA?
Answer: A
Explanation:
CMS specifically includes deep vein thrombosis and pulmonary embolism following certain orthopedic procedures, including total knee replacement and hip replacement, among Hospital-Acquired Conditions subject to the HAC/POA payment provisions. Therefore, option C is correct.
Under the IPPS HAC payment policy, qualifying conditions that were not present on admission may lose their normal CC/MCC effect for MS-DRG assignment when all applicable criteria are met. This makes accurate POA determination essential in CDI and coding.
Pressure ulcers are also part of the HAC framework, but the CMS category historically applies specifically to Stage III and Stage IV pressure ulcers. An unstageable pressure ulcer does not automatically satisfy the Stage III/IV HAC category merely because it is severe or clinically significant. CMS materials distinguish an unstageable ulcer from a documented Stage III or IV ulcer.
Postoperative pneumonia and septic shock are not, by themselves, the specified HAC category represented by the answer choices.
The CCDS blueprint specifically requires candidates to identify CMS-designated HACs and understand the effect of POA assignment on payment.
CCDS Reference Topics: IPPS; Hospital-Acquired Conditions; POA; MS-DRG adjustment.
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NEW QUESTION # 60
What type of query is needed to compliantly address a scenario in which clinical indicators of a diagnosis exist, but for which no diagnosis has been documented in the medical record?
Answer: D
Explanation:
A multiple-choice query is appropriate when clinical indicators support the possibility of a condition but the diagnosis itself has not yet been documented. The query may present clinically reasonable diagnostic choices supported by the patient's record while also allowing an alternative response such as "other, please specify" or an inability to determine.
A yes/no query is not the appropriate format for introducing a new, previously undocumented diagnosis.
AHIMA/ACDIS guidance has specifically distinguished this situation from circumstances where yes/no clarification may be used for an already documented condition, POA determination, cause-and-effect clarification, or similar defined purposes.
A clinical-validation query addresses the opposite problem: a diagnosis is already documented, but the health record appears to lack sufficient clinical support for that diagnosis. Therefore, option C does not match the scenario.
A cause-and-effect query would be appropriate when two documented conditions require clarification of their relationship, not when the fundamental issue is the absence of a diagnosis.
Current AHIMA/ACDIS guidance continues to permit multiple-choice queries supported by relevant clinical indicators and emphasizes neutral wording.
CCDS Reference Topics: Compliant query formats; missing diagnosis; clinical validation; nonleading queries.
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NEW QUESTION # 61
A patient undergoes colorectal surgery. On postoperative day 2, the physician documents "ileus." The record shows absent bowel sounds and abdominal distention, but the surgeon also states that delayed bowel function is expected at this stage of recovery. Which action is MOST appropriate?
Answer: B
Explanation:
The record contains uncertainty regarding whether the documented ileus represents expected postoperative physiology or a clinically significant complication, making provider clarification appropriate.
Temporary impairment of gastrointestinal motility is common following abdominal surgery. Therefore, the mere occurrence of an ileus after surgery does not automatically establish a complication of care. Conversely, prolonged or clinically significant postoperative ileus requiring substantial treatment, extended hospitalization, nasogastric decompression, or other interventions may warrant distinct documentation.
The CDI specialist must not infer the complication relationship solely from timing. The Official Guidelines emphasize that a condition occurring after medical or surgical care is not automatically classified as a complication; appropriate provider documentation of the relationship and clinical significance is required where applicable.
Option C is also incorrect because postoperative ileus can be a reportable condition when clinically significant and appropriately documented. Option D substitutes a separate diagnosis without provider support.
The query should provide relevant duration, symptoms, imaging, diet status, nasogastric tube use, treatment, and expected postoperative course while allowing the surgeon to characterize the condition.
CCDS Reference Topics: Postoperative ileus; complications of care; postoperative documentation; clinical clarification.
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NEW QUESTION # 62
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The CCDS exam is one of the most valuable certification exams. The Certified Clinical Documentation Specialist (CCDS) certification exam opens a door for beginners or experienced PassReview professionals to enhance in-demand skills and gain knowledge. CCDS exam credential is proof of candidates' expertise and knowledge. After getting success in the Certified Clinical Documentation Specialist (CCDS) certification exam, candidates can put their careers on the fast route and achieve their goals in a short period of time.
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