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| Section | Weight | Objectives |
|---|---|---|
| Medical record documentation | 19.17% | - Situations in which queries are not appropriate - Types of physician queries - Compliant and noncompliant queries - Health record elements used for diagnosis and procedure code assignment - Translating clinical indicators into compliant queries - Provider role and diagnosis code assignment - Documentation requiring clarification - When a physician query is warranted - Physician query formats - ACDIS/AHIMA Guidelines for Achieving a Compliant Query Practice - Clinical indicators - Addressing diagnoses without clinical support |
| Healthcare regulations, reimbursement, and documentation requirements related to the IPPS | 12.5% | - Documentation and medical necessity of setting - Coding and billing practices vulnerable to denial - Documentation impact on IPPS reimbursement - Case mix index (CMI) - Complication/comorbidity (CC) - Major complication/comorbidity (MCC) - Medical staff and clinical staff documentation responsibilities - Principal diagnosis and medical necessity - Medicare contractors and their impact on CDI - Medicare Severity Diagnosis Related Groups (MS-DRGs) - IPPS and its updates and revisions - Inpatient admission criteria and CMS Two-Midnight Rule |
| Healthcare facility CDI program analysis | 8.33% | - Severity of illness and risk of mortality - Physician performance measurement - CC/MCC capture - Provider response rates - Basic computer and software application skills - Publicly reported data - Case mix index (CMI) - Hospital Value-Based Purchasing measures - Tracking and trending physician, department, and hospital performance - Patient Safety Indicators - Hospital-specific financial data - CDI specialist productivity metrics - CDI program forecasting - High-frequency DRGs - PEPPER data |
| Professionalism, ethics, and compliance | 9.17% | - Compliance risks indicated by PEPPER - Potential DRG creep - Leading queries - DRG compliance initiatives - Medical record confidentiality - CDI department goals beyond reimbursement |
| Impact of reportable diagnoses on quality of care | 8.33% | - Hospital Readmissions Reduction Program - Healthcare-associated infections and complication codes - Hospital-Acquired Condition Reduction Program - 30-day mortality measures - Mortality reviews and observed/expected ratios - Coded data elements affecting Patient Safety Indicators - CDI impact on Hospital Value-Based Purchasing - Patient Safety Indicators - Hospital Value-Based Purchasing - Quality data from record abstraction and claims data - Documentation and code assignment impact on mortality index - Hospital Inpatient Quality Reporting Program |
| Communication skills | 9.17% | - Physician education forms and tools - Verbal versus written physician communication - Reconciling CDI working DRGs with final coded DRGs - Roles and responsibilities of CDI specialists - Effective and non-confrontational physician communication - Educational presentations for healthcare departments and administration - Roles and responsibilities of coders working with CDI departments |
| Official Guidelines for Coding and Reporting | 14.17% | - Working DRG assignment for multiple diagnoses - Present on admission indicators - Principal diagnosis assignment - AHA Coding Clinic - Official Guidelines for Coding and Reporting updates - Discharge dispositions and transfers - Coding guidelines for principal diagnosis selection - Hospital-acquired conditions - Secondary diagnosis assignment |
| Anatomy and physiology, pathophysiology, pharmacology, and medical terminology | 19.17% | - Standard medical abbreviations - Diseases and disorders of the musculoskeletal system - Infectious and parasitic diseases - Diseases and disorders of the digestive system - Myeloproliferative diseases and disorders and poorly differentiated neoplasms - Diagnostic tests as clinical indicators - Diseases and disorders of the circulatory system - Diseases and disorders of the skin, subcutaneous tissue, and breast - Endocrine, nutritional, and metabolic diseases and disorders - Pharmaceuticals and disease processes - HIV infections - Injuries, poisonings, and toxic effects of drugs - Alcohol/drug use and alcohol/drug-induced organic brain disorders - Diseases and disorders of the blood and blood-forming organs and immunological disorders - Diseases and disorders of the respiratory system - Diseases and disorders of the hepatobiliary system - Diseases and disorders of the nervous system - Clinical indicators and query opportunities by Major Diagnostic Category - Mental diseases and disorders - Medications as clinical indicators - Diseases and disorders of the kidney and urinary tract |
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NEW QUESTION # 76
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 # 77
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: B
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 # 78
A CDI specialist identifies fever, leukocytosis, tachycardia, positive blood cultures, and IV antibiotic treatment. No infectious diagnosis has been documented. Which query approach is MOST compliant?
Answer: B
Explanation:
The most compliant approach is to present the patient-specific clinical indicators objectively and request clarification using clinically reasonable choices without predetermining the diagnosis.
Neither the CDI specialist nor coder independently diagnoses sepsis from fever, leukocytosis, tachycardia, cultures, or antibiotic therapy. These findings create a legitimate clarification opportunity, but the responsible provider must determine whether the patient has sepsis, bacteremia, a localized infection, contamination, another condition, or no definitive diagnosis.
Option A is leading because it instructs the provider to document a specific diagnosis. Option B is problematic because a yes/no format would effectively introduce a new diagnosis that has not previously been documented. Option D violates basic coding principles because treatment alone does not establish a provider diagnosis.
The August 2026 ACDIS/AHIMA guidance is the current foundational standard for compliant query practice and supersedes earlier versions. It applies across inpatient and other healthcare environments and emphasizes defensible documentation clarification processes.
CCDS Reference Topics: Compliant queries; missing diagnosis; multiple-choice queries; clinical indicators; provider independence.
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NEW QUESTION # 79
The progress note on hospital day 2 of a patient's admission states that the patient got up from the bed to go to the bathroom just after housekeeping had mopped the floor. The patient slipped and fell onto the floor, sustaining a broken wrist. The diagnosis of a fractured wrist will:
Answer: D
Explanation:
The fracture occurred after inpatient admission as the result of a hospital fall, placing it within CMS's Hospital-Acquired Condition category for Falls and Trauma when the applicable fracture code is included in the HAC code list. CMS's FY 2026 MS-DRG Definitions Manual continues to identify qualifying fracture codes within HAC 05.
The fracture must still be coded; therefore, option D is incorrect. Because it clearly developed after admission, it would not appropriately receive POA indicator "U," which indicates insufficient documentation to determine whether the condition was present on admission.
For qualifying HAC diagnoses that are not POA, CMS payment logic prevents the hospital from receiving the higher MS-DRG payment that would otherwise result solely from the condition's CC/MCC status. Thus, option B expresses the intended payment effect.
This distinction is central to CDI practice: a hospital-acquired diagnosis does not disappear from the record or coding. It remains reportable for clinical and quality purposes, but certain qualifying HACs are treated differently in MS-DRG payment calculations.
CCDS Reference Topics: HACs; POA indicators; Falls and Trauma; MS-DRG payment adjustment.
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NEW QUESTION # 80
A patient accidentally takes twice the prescribed dose of warfarin and develops gastrointestinal bleeding.
Which coding concept applies?
Answer: B
Explanation:
Taking more medication than prescribed constitutes poisoning under ICD-10-CM drug-event rules. The drug may have been correctly prescribed, but the patient took an incorrect amount.
For poisoning, the applicable poisoning code is generally sequenced first, followed by codes identifying manifestations such as gastrointestinal bleeding.
This differs from an adverse effect, in which a drug is correctly prescribed and properly administered but causes an undesirable reaction. In adverse-effect scenarios, the nature of the adverse effect is coded first, followed by the drug code with the appropriate adverse-effect character.
Underdosing applies when the patient takes less of a medication than prescribed, whether intentionally or unintentionally. It does not describe excessive dosing.
For CDI specialists, determining whether an event represents poisoning, adverse effect, or underdosing requires careful review of how the medication was prescribed and actually taken. Phrases such as "warfarin- related bleeding" may not always provide enough information to determine the correct classification.
A clarification query may therefore be appropriate when dose, intent, or medication-use circumstances are unclear.
CCDS Reference Topics: Poisoning; adverse effects; underdosing; medication events; sequencing.
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NEW QUESTION # 81
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