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| Section | Weight | Objectives |
|---|---|---|
| Topic 1: Official Guidelines for Coding and Reporting | 14.17% | - Official Guidelines for Coding and Reporting updates - Working DRG assignment for multiple diagnoses - Present on admission indicators - Hospital-acquired conditions - Coding guidelines for principal diagnosis selection - Secondary diagnosis assignment - Principal diagnosis assignment - AHA Coding Clinic - Discharge dispositions and transfers |
| Topic 2: Professionalism, ethics, and compliance | 9.17% | - Potential DRG creep - Leading queries - CDI department goals beyond reimbursement - Compliance risks indicated by PEPPER - Medical record confidentiality - DRG compliance initiatives |
| Topic 3: Healthcare regulations, reimbursement, and documentation requirements related to the IPPS | 12.5% | - Complication/comorbidity (CC) - Case mix index (CMI) - Documentation impact on IPPS reimbursement - Principal diagnosis and medical necessity - Medical staff and clinical staff documentation responsibilities - Medicare Severity Diagnosis Related Groups (MS-DRGs) - Major complication/comorbidity (MCC) - Coding and billing practices vulnerable to denial - Documentation and medical necessity of setting - Medicare contractors and their impact on CDI - Inpatient admission criteria and CMS Two-Midnight Rule - IPPS and its updates and revisions |
| Topic 4: Medical record documentation | 19.17% | - Clinical indicators - When a physician query is warranted - Documentation requiring clarification - Situations in which queries are not appropriate - Translating clinical indicators into compliant queries - Provider role and diagnosis code assignment - Addressing diagnoses without clinical support - Compliant and noncompliant queries - ACDIS/AHIMA Guidelines for Achieving a Compliant Query Practice - Physician query formats - Types of physician queries - Health record elements used for diagnosis and procedure code assignment |
| Topic 5: Healthcare facility CDI program analysis | 8.33% | - Case mix index (CMI) - Tracking and trending physician, department, and hospital performance - CDI specialist productivity metrics - Patient Safety Indicators - Severity of illness and risk of mortality - High-frequency DRGs - Hospital Value-Based Purchasing measures - Hospital-specific financial data - Provider response rates - PEPPER data - CC/MCC capture - Publicly reported data - Basic computer and software application skills - CDI program forecasting - Physician performance measurement |
| Topic 6: Communication skills | 9.17% | - Roles and responsibilities of coders working with CDI departments - Physician education forms and tools - Educational presentations for healthcare departments and administration - Reconciling CDI working DRGs with final coded DRGs - Verbal versus written physician communication - Effective and non-confrontational physician communication - Roles and responsibilities of CDI specialists |
| Topic 7: Anatomy and physiology, pathophysiology, pharmacology, and medical terminology | 19.17% | - Diseases and disorders of the respiratory system - Diseases and disorders of the blood and blood-forming organs and immunological disorders - Mental diseases and disorders - Diseases and disorders of the circulatory system - Infectious and parasitic diseases - Diagnostic tests as clinical indicators - Diseases and disorders of the nervous system - HIV infections - Diseases and disorders of the skin, subcutaneous tissue, and breast - Medications as clinical indicators - Clinical indicators and query opportunities by Major Diagnostic Category - Diseases and disorders of the musculoskeletal system - Myeloproliferative diseases and disorders and poorly differentiated neoplasms - Diseases and disorders of the kidney and urinary tract - Standard medical abbreviations - Diseases and disorders of the hepatobiliary system - Pharmaceuticals and disease processes - Diseases and disorders of the digestive system - Injuries, poisonings, and toxic effects of drugs - Endocrine, nutritional, and metabolic diseases and disorders - Alcohol/drug use and alcohol/drug-induced organic brain disorders |
| Topic 8: Impact of reportable diagnoses on quality of care | 8.33% | - Hospital Readmissions Reduction Program - Patient Safety Indicators - Hospital-Acquired Condition Reduction Program - 30-day mortality measures - Coded data elements affecting Patient Safety Indicators - Hospital Inpatient Quality Reporting Program - Mortality reviews and observed/expected ratios - Hospital Value-Based Purchasing - Documentation and code assignment impact on mortality index - Quality data from record abstraction and claims data - Healthcare-associated infections and complication codes - CDI impact on Hospital Value-Based Purchasing |
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NEW QUESTION # 137
An arterial blood gas shows pH 7.24, PaCO# 72 mmHg, and HCO## 30 mEq/L in a patient with COPD and acute respiratory distress. Which acid-base abnormality is primarily demonstrated?
Answer: B
Explanation:
The arterial blood gas primarily demonstrates respiratory acidosis. The pH is significantly acidemic at 7.24, while PaCO# is markedly elevated at 72 mmHg. Because carbon dioxide acts as an acid through the carbonic acid buffering system, CO# retention lowers blood pH.
The bicarbonate of 30 mEq/L is mildly elevated, suggesting some renal compensation, which may occur in patients with chronic CO# retention from COPD. However, the substantial acidemia indicates that compensation is insufficient and an acute component may be present.
In a COPD patient with acute respiratory distress, such findings can create an appropriate clinical basis for clarification of acute or acute-on-chronic hypercapnic respiratory failure when other supporting indicators are present, such as worsening work of breathing, altered mental status, escalating oxygen needs, BiPAP, or intubation.
The CDI specialist should not independently equate every abnormal ABG with respiratory failure. The provider determines the clinical diagnosis.
Respiratory alkalosis would involve reduced PaCO#. Metabolic acidosis generally involves reduced bicarbonate as the primary disturbance, while metabolic alkalosis involves primary bicarbonate elevation with alkalemia.
CCDS Reference Topics: ABG interpretation; respiratory acidosis; hypercapnia; COPD; respiratory failure.
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NEW QUESTION # 138
A 91-year-old has a past medical history of heart failure, COPD, and adenocarcinoma of the lung and brain.
The patient presents with shortness of breath, weakness, and pain. His vital signs are T 99°F, RR 18, BP 108
/74, and pulse 110. Pulse oximetry is 98% on 2 L nasal cannula. He is admitted with HCAP, COPD, and diastolic heart failure.
Initial laboratory values are:
Hgb: 9.0
Sodium: 134.0
WBC: 12.9
The physician orders antibiotics and 2 L nasal cannula. Based upon the information provided above, which of the following queries would be MOST appropriate?
Answer: B
Explanation:
The most appropriate clarification concerns the underlying cause/type of pneumonia. The record documents
"HCAP," but that term does not identify a specific causative organism or pathophysiologic pneumonia type.
The patient is being actively treated with antibiotics, has leukocytosis, and was admitted with pneumonia- related documentation, creating a legitimate opportunity to clarify clinically supported specificity.
The other options are weaker. Hemoglobin of 9.0 supports anemia but does not establish acute blood loss anemia without evidence of active/recent blood loss or an acute decline. Sodium of 134 mEq/L is only mildly reduced and, without treatment or other clinical significance, does not by itself justify seeking a diagnosis solely from the laboratory value.
The record already specifies diastolic heart failure. Although acuity could sometimes warrant clarification, the presented findings do not strongly establish acute decompensated heart failure: oxygen requirement is modest, saturation is 98%, and no pulmonary edema, diuretic escalation, or other acute HF indicators are provided.
The query should remain neutral and allow the provider to identify the pneumonia type only if clinically determinable.
CCDS Reference Topics: Pneumonia specificity; clinical indicators; documentation clarification; query prioritization.
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NEW QUESTION # 139
A CDI specialist's working MS-DRG differs from the final coder-assigned MS-DRG in 18% of reviewed cases. What is the BEST initial management response?
Answer: A
Explanation:
A significant mismatch rate should trigger structured CDI/coding reconciliation, not an assumption that either department is wrong.
Working MS-DRGs are provisional. Final coding may change because of discharge-summary diagnoses, operative reports, pathology results, late physician clarification, Coding Clinic guidance, sequencing conventions, final procedure coding, CC/MCC exclusions, or other grouper logic unavailable during the concurrent CDI review.
The manager should categorize mismatch causes. Useful categories include principal-diagnosis differences, missed secondary diagnoses, procedure-code differences, coding-guideline interpretation, query results, discharge documentation, and technical grouper issues.
Patterns can then identify whether education is needed for CDI specialists, coding professionals, physicians, or multiple groups.
Requiring coding staff to adopt the CDI working DRG would undermine coding independence and final coding accountability. Excluding mismatches from metrics would conceal an important quality indicator.
CMS confirms that the FY 2026 MS-DRG Definitions Manual contains the complete grouper logic for Version 43.1, making current grouper rules essential when evaluating discrepancies.
CCDS Reference Topics: MS-DRG reconciliation; CDI/coder agreement; program analysis; education; grouper logic.
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NEW QUESTION # 140
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: D
NEW QUESTION # 141
A patient's hemoglobin decreases from 13.1 g/dL before surgery to 7.4 g/dL afterward. Estimated intraoperative blood loss is 1,200 mL, and the patient receives two units of packed red blood cells. The physician documents only "postoperative anemia." Which clarification is MOST appropriate?
Answer: A
Explanation:
The significant hemoglobin decline, documented surgical blood loss, and transfusion requirement create a strong clinical basis to clarify whether the patient has acute blood loss anemia or another form of postoperative anemia.
However, neither the hemoglobin value nor transfusion independently establishes the diagnosis. The provider must determine the clinical significance and etiology. A postoperative hemoglobin decline can reflect actual hemorrhage, hemodilution, preexisting anemia, expected procedural blood loss, or multiple factors.
A compliant query could present baseline and postoperative hemoglobin levels, estimated blood loss, transfusion, hemodynamic findings, and relevant treatment, then ask the provider to characterize the anemia.
The CDI specialist should also distinguish anemia from a postprocedural complication. Even if acute blood loss anemia is documented, that does not automatically mean a surgical complication occurred. Complication status may require separate provider clarification depending on the record.
Hemolytic anemia has a different pathophysiology involving red-cell destruction, while chronic iron deficiency cannot be inferred from the acute postoperative course.
CCDS Reference Topics: Acute blood loss anemia; postoperative documentation; transfusion; clinical indicators; complications of care.
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NEW QUESTION # 142
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