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| Section | Weight | Objectives |
|---|---|---|
| Healthcare facility CDI program analysis | 8.33% | - Provider response rates - CC/MCC capture - CDI specialist productivity metrics - High-frequency DRGs - PEPPER data - CDI program forecasting - Case mix index (CMI) - Severity of illness and risk of mortality - Tracking and trending physician, department, and hospital performance - Basic computer and software application skills - Hospital-specific financial data - Patient Safety Indicators - Publicly reported data - Physician performance measurement - Hospital Value-Based Purchasing measures |
| Medical record documentation | 19.17% | - Clinical indicators - Situations in which queries are not appropriate - Health record elements used for diagnosis and procedure code assignment - Physician query formats - Documentation requiring clarification - ACDIS/AHIMA Guidelines for Achieving a Compliant Query Practice - Translating clinical indicators into compliant queries - Compliant and noncompliant queries - When a physician query is warranted - Addressing diagnoses without clinical support - Types of physician queries - Provider role and diagnosis code assignment |
| Impact of reportable diagnoses on quality of care | 8.33% | - Hospital Value-Based Purchasing - Hospital Readmissions Reduction Program - Mortality reviews and observed/expected ratios - Documentation and code assignment impact on mortality index - CDI impact on Hospital Value-Based Purchasing - Hospital-Acquired Condition Reduction Program - Patient Safety Indicators - Quality data from record abstraction and claims data - Healthcare-associated infections and complication codes - Coded data elements affecting Patient Safety Indicators - 30-day mortality measures - Hospital Inpatient Quality Reporting Program |
| Healthcare regulations, reimbursement, and documentation requirements related to the IPPS | 12.5% | - Medicare Severity Diagnosis Related Groups (MS-DRGs) - Complication/comorbidity (CC) - Case mix index (CMI) - Major complication/comorbidity (MCC) - Documentation impact on IPPS reimbursement - IPPS and its updates and revisions - Medical staff and clinical staff documentation responsibilities - Coding and billing practices vulnerable to denial - Principal diagnosis and medical necessity - Documentation and medical necessity of setting - Medicare contractors and their impact on CDI - Inpatient admission criteria and CMS Two-Midnight Rule |
| Communication skills | 9.17% | - Roles and responsibilities of CDI specialists - Verbal versus written physician communication - Physician education forms and tools - Effective and non-confrontational physician communication - Educational presentations for healthcare departments and administration - Roles and responsibilities of coders working with CDI departments - Reconciling CDI working DRGs with final coded DRGs |
| Anatomy and physiology, pathophysiology, pharmacology, and medical terminology | 19.17% | - Diseases and disorders of the circulatory system - Alcohol/drug use and alcohol/drug-induced organic brain disorders - Diseases and disorders of the digestive system - Medications as clinical indicators - Diseases and disorders of the nervous system - Diseases and disorders of the hepatobiliary system - Endocrine, nutritional, and metabolic diseases and disorders - Diseases and disorders of the musculoskeletal system - Diseases and disorders of the respiratory system - Mental diseases and disorders - Diseases and disorders of the kidney and urinary tract - Diagnostic tests as clinical indicators - Myeloproliferative diseases and disorders and poorly differentiated neoplasms - Diseases and disorders of the skin, subcutaneous tissue, and breast - HIV infections - Infectious and parasitic diseases - Injuries, poisonings, and toxic effects of drugs - Standard medical abbreviations - Pharmaceuticals and disease processes - Clinical indicators and query opportunities by Major Diagnostic Category - Diseases and disorders of the blood and blood-forming organs and immunological disorders |
| Official Guidelines for Coding and Reporting | 14.17% | - Principal diagnosis assignment - Working DRG assignment for multiple diagnoses - Discharge dispositions and transfers - Present on admission indicators - Coding guidelines for principal diagnosis selection - Official Guidelines for Coding and Reporting updates - Secondary diagnosis assignment - AHA Coding Clinic - Hospital-acquired conditions |
| Professionalism, ethics, and compliance | 9.17% | - Medical record confidentiality - Leading queries - Compliance risks indicated by PEPPER - CDI department goals beyond reimbursement - DRG compliance initiatives - Potential DRG creep |
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NEW QUESTION # 134
A patient's baseline creatinine is 1.1 mg/dL. On admission it is 1.2 mg/dL, and 36 hours later it rises to 2.4 mg
/dL after prolonged hypotension. Urine output declines substantially. Which condition presents the strongest clarification opportunity?
Answer: D
Explanation:
The abrupt increase in serum creatinine and reduction in urine output strongly support consideration of acute kidney injury (AKI). The patient's creatinine approximately doubled from the established baseline within a short period, and the episode follows significant hypotension, a recognized cause of acute renal hypoperfusion and potentially ischemic tubular injury.
Chronic kidney disease cannot be established from an acute creatinine change alone. CKD requires evidence that renal abnormalities persist chronically, generally over a period of at least several months. End-stage renal disease represents advanced chronic renal failure and is clearly unsupported by this scenario. Nephrotic syndrome would require a different constellation, particularly substantial proteinuria, hypoalbuminemia, and edema.
The CDI specialist should not independently diagnose AKI based solely on laboratory values. Rather, these findings provide the clinical basis for a neutral provider query if the diagnosis has not been documented.
Relevant indicators could include baseline and current creatinine, urine output, hypotension, fluid resuscitation, nephrology assessment, medications, and renal replacement therapy if applicable.
The CCDS competency framework expects candidates to interpret renal laboratory findings and recognize clinically significant documentation opportunities.
CCDS Reference Topics: Acute kidney injury; renal pathophysiology; creatinine trends; clinical indicators.
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NEW QUESTION # 135
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: D
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 # 136
A patient is admitted for UTI with AMS. The physician documents "UTI due to Escherichia coli." CT scan of the head is negative, with AMS improving and family reporting the patient is now at baseline. Admission creatinine is 1.2 mg/dL and sodium is 146 mEq/L. Plan is discharge home today.
The CDI specialist should query for the:
Answer: B
Explanation:
The clinically meaningful documentation gap concerns what condition actually occasioned the inpatient admission and whether the altered mental status represents a defined diagnosis associated with the episode.
The record identifies a UTI due to E. coli, but the patient also presented with AMS significant enough to undergo head CT evaluation. The AMS subsequently resolved to baseline.
A creatinine of 1.2 mg/dL alone does not establish acute kidney injury because AKI requires evidence of an acute change from baseline and appropriate clinical context. Similarly, sodium of 146 mEq/L is only minimally elevated and, without clinical evaluation or treatment demonstrating significance, does not justify a query designed to generate hypernatremia.
Merely clarifying AMS as acute versus chronic is also less useful than determining the actual diagnosis explaining the altered mental state and its relationship to the admission. Depending on provider judgment and supporting evidence, possibilities could include an acute encephalopathic process, delirium, symptoms associated with infection, or another condition.
The query should remain neutral and should not presume that the UTI caused the AMS.
CCDS Reference Topics: Principal diagnosis clarification; AMS; clinical indicators; query prioritization; documentation integrity.
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NEW QUESTION # 137
At discharge, the attending physician documents, "Probable aspiration pneumonia causing the patient's respiratory symptoms." The patient is an inpatient. No subsequent documentation rules out aspiration pneumonia. How should the diagnosis be handled for inpatient coding?
Answer: C
Explanation:
For an inpatient discharge, a diagnosis documented as "probable" may be coded as though the condition existed or was established when it remains documented as such at discharge.
The FY 2026 ICD-10-CM Official Guidelines provide a specific inpatient rule for uncertain diagnoses documented at the time of discharge. Terms such as probable, suspected, likely, questionable, possible, still to be ruled out, compatible with, and consistent with are coded as if the condition existed, because the diagnostic workup and treatment generally correspond to the suspected condition.
Therefore, aspiration pneumonia-not merely the respiratory symptoms-is the appropriate condition to code in this scenario.
This rule is specific to inpatient hospital coding and should not be generalized to outpatient encounters, where uncertain diagnoses are handled differently and symptoms or confirmed conditions are generally reported instead.
A query would still be appropriate if the documentation were contradictory, clinically ambiguous, or if multiple competing diagnoses remained without sufficient clarification. But the word "probable" itself does not create a mandatory inpatient query.
CCDS Reference Topics: Inpatient uncertain diagnoses; aspiration pneumonia; discharge documentation; Official Guidelines.
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NEW QUESTION # 138
The attending physician documents "severe protein-calorie malnutrition." The dietitian's assessment documents normal nutritional intake, stable body weight, no fat loss, and no muscle wasting. What should the CDI specialist do?
Answer: A
Explanation:
This is an appropriate clinical validation query because the provider has documented a diagnosis while the available clinical information appears inconsistent with that diagnosis.
The CDI specialist should not automatically accept every documented diagnosis when substantial contradictory clinical evidence exists. Conversely, CDI cannot independently delete the physician's diagnosis or replace the physician's clinical judgment.
The query should objectively identify the documented severe malnutrition and relevant contradictory findings-for example, stable weight, adequate nutritional intake, and absence of documented muscle or fat loss-and ask the provider to clarify whether severe malnutrition remains clinically appropriate, whether another nutritional condition better describes the patient, whether the diagnosis has been ruled out, or whether additional clinical reasoning supports it.
The query must remain neutral and should not mention the MCC status or potential reimbursement effect of severe malnutrition.
The August 2026 ACDIS/AHIMA compliant-query guidance supersedes previous editions and is the current foundational standard for compliant documentation clarification.
CCDS Reference Topics: Clinical validation; malnutrition; conflicting clinical indicators; compliant queries; documentation integrity.
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NEW QUESTION # 139
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