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| Section | Weight | Objectives |
|---|---|---|
| Topic 1: Professionalism, ethics, and compliance | 9.17% | - DRG compliance initiatives - CDI department goals beyond reimbursement - Compliance risks indicated by PEPPER - Potential DRG creep - Medical record confidentiality - Leading queries |
| Topic 2: Impact of reportable diagnoses on quality of care | 8.33% | - Healthcare-associated infections and complication codes - Hospital-Acquired Condition Reduction Program - Coded data elements affecting Patient Safety Indicators - Hospital Value-Based Purchasing - Patient Safety Indicators - Quality data from record abstraction and claims data - Hospital Inpatient Quality Reporting Program - 30-day mortality measures - Mortality reviews and observed/expected ratios - Hospital Readmissions Reduction Program - CDI impact on Hospital Value-Based Purchasing - Documentation and code assignment impact on mortality index |
| Topic 3: Communication skills | 9.17% | - Effective and non-confrontational physician communication - Educational presentations for healthcare departments and administration - Reconciling CDI working DRGs with final coded DRGs - Physician education forms and tools - Verbal versus written physician communication - Roles and responsibilities of CDI specialists - Roles and responsibilities of coders working with CDI departments |
| Topic 4: Healthcare facility CDI program analysis | 8.33% | - Hospital Value-Based Purchasing measures - Severity of illness and risk of mortality - Tracking and trending physician, department, and hospital performance - High-frequency DRGs - PEPPER data - Hospital-specific financial data - CDI specialist productivity metrics - Publicly reported data - Physician performance measurement - Case mix index (CMI) - Provider response rates - Basic computer and software application skills - Patient Safety Indicators - CC/MCC capture - CDI program forecasting |
| Topic 5: Official Guidelines for Coding and Reporting | 14.17% | - Principal diagnosis assignment - Working DRG assignment for multiple diagnoses - Secondary diagnosis assignment - Present on admission indicators - Hospital-acquired conditions - Coding guidelines for principal diagnosis selection - Discharge dispositions and transfers - AHA Coding Clinic - Official Guidelines for Coding and Reporting updates |
| Topic 6: Medical record documentation | 19.17% | - Provider role and diagnosis code assignment - Documentation requiring clarification - Health record elements used for diagnosis and procedure code assignment - ACDIS/AHIMA Guidelines for Achieving a Compliant Query Practice - Compliant and noncompliant queries - Addressing diagnoses without clinical support - Situations in which queries are not appropriate - Physician query formats - Types of physician queries - Translating clinical indicators into compliant queries - Clinical indicators - When a physician query is warranted |
| Topic 7: Healthcare regulations, reimbursement, and documentation requirements related to the IPPS | 12.5% | - Medicare contractors and their impact on CDI - IPPS and its updates and revisions - Principal diagnosis and medical necessity - Medical staff and clinical staff documentation responsibilities - Coding and billing practices vulnerable to denial - Case mix index (CMI) - Medicare Severity Diagnosis Related Groups (MS-DRGs) - Inpatient admission criteria and CMS Two-Midnight Rule - Major complication/comorbidity (MCC) - Documentation and medical necessity of setting - Complication/comorbidity (CC) - Documentation impact on IPPS reimbursement |
| Topic 8: Anatomy and physiology, pathophysiology, pharmacology, and medical terminology | 19.17% | - Clinical indicators and query opportunities by Major Diagnostic Category - Injuries, poisonings, and toxic effects of drugs - Diseases and disorders of the kidney and urinary tract - Diseases and disorders of the blood and blood-forming organs and immunological disorders - Endocrine, nutritional, and metabolic diseases and disorders - Diseases and disorders of the skin, subcutaneous tissue, and breast - Standard medical abbreviations - Diseases and disorders of the circulatory system - Diseases and disorders of the respiratory system - Infectious and parasitic diseases - Alcohol/drug use and alcohol/drug-induced organic brain disorders - Diagnostic tests as clinical indicators - HIV infections - Diseases and disorders of the hepatobiliary system - Diseases and disorders of the musculoskeletal system - Medications as clinical indicators - Diseases and disorders of the nervous system - Mental diseases and disorders - Myeloproliferative diseases and disorders and poorly differentiated neoplasms - Pharmaceuticals and disease processes - Diseases and disorders of the digestive system |
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問題 #93
A pregnant female presents to the ED with diarrhea, cramps, nausea, and vomiting for the past 12 hours. She was admitted with enteritis due to Clostridium difficile and provided IV fluids. Which of the following coding guidelines applies to determining the principal diagnosis for this patient?
答案：C
解題說明：
For a pregnant patient, the first coding consideration is the Chapter 15 obstetric guideline unless the provider explicitly documents that the pregnancy is incidental to the encounter. ICD-10-CM codes from O00-O9A have sequencing priority over codes from other chapters when a condition complicates pregnancy, childbirth, or the puerperium.
Therefore, although the patient's underlying clinical disease is Clostridium difficile enteritis, the principal- diagnosis analysis begins with the applicable pregnancy-complication code. An additional infectious-disease code would then be used as appropriate to identify the specific infection. The infectious and parasitic disease chapter does not override the obstetric sequencing rules.
Signs such as diarrhea, cramps, nausea, and vomiting are also not the principal coding focus once a definitive diagnosis-C. difficile enteritis-has been established. Similarly, an etiology/manifestation sequencing convention is not the controlling rule in this scenario.
The critical CCDS concept is recognition of chapter-specific sequencing rules. A CDI specialist reviewing pregnant patients must recognize that otherwise standard principal-diagnosis logic may be superseded by obstetric instructions.
CCDS Reference Topics: Official Guidelines for Coding and Reporting-Chapter 15; principal diagnosis selection; chapter-specific sequencing.
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問題 #94
A patient is admitted with a stage 2 sacral pressure ulcer. During the hospitalization, the ulcer progresses and is documented as stage 3 at the same site. How should the pressure ulcer be reported?
答案：A
解題說明：
The FY 2026 ICD-10-CM Official Guidelines specifically address a pressure ulcer that progresses to a higher stage during an inpatient admission. Two codes are assigned: one representing the site and stage present on admission and another representing the same ulcer site at the highest stage documented during the hospitalization.
Therefore, this patient's stage 2 sacral pressure ulcer on admission and subsequent progression to stage 3 must both be represented according to the applicable coding instructions.
The distinction is important for both clinical and quality purposes because the record must accurately show what condition existed when the patient entered the hospital and how the wound subsequently evolved.
Coding only the stage 3 ulcer would lose information about its status at admission. Coding only stage 2 would fail to represent the deterioration that occurred during the stay.
Pressure-ulcer staging is also one of the circumstances in which qualified non-provider clinician documentation, such as wound-care nursing documentation, may be used to establish stage when the diagnosis itself is appropriately documented.
For CDI, accurate wound location, stage, progression, and POA documentation are essential because advanced pressure injuries may influence MS-DRG severity and hospital quality reporting.
CCDS Reference Topics: Pressure ulcers; staging; POA; wound-care documentation; Official Guidelines.
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問題 #95
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?
答案：D
問題 #96
Which of the following conditions demonstrates the greatest risk of mortality in a 77-year-old patient?
答案：D
解題說明：
Among the choices presented, sepsis associated with a urinary tract infection represents the strongest overall mortality-risk condition. Sepsis is a systemic, potentially life-threatening response to infection and is associated with substantially greater mortality risk than an uncomplicated localized infection, particularly in an elderly patient.
Risk of mortality in CDI is not determined merely by whether a diagnosis is a CC or MCC. Risk-adjustment systems evaluate the complete clinical profile, including principal diagnosis, secondary diagnoses, age, organ dysfunction, severity interactions, and other patient characteristics. Thus, reimbursement severity and predicted mortality are related concepts but are not interchangeable.
The history of mastectomy ten years earlier does not itself materially increase the current acute severity unless active malignancy or another relevant condition is present. The principal acute concern in option D is sepsis.
COPD with respiratory failure and NSTEMI with acute systolic heart failure are also high-risk presentations and require complete documentation; however, the question's intended risk-adjustment comparison identifies the septic presentation as carrying the greatest mortality concern.
If acute organ dysfunction were linked to sepsis, documentation of severe sepsis would further increase the represented clinical severity.
CCDS Reference Topics: Risk of mortality; severity adjustment; sepsis; quality reporting; distinction between MS-DRG severity and ROM.
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問題 #97
A patient with cirrhosis presents with confusion and asterixis. Ammonia is elevated and the patient improves after lactulose administration. The physician documents "altered mental status due to liver disease." Which clarification would provide the MOST clinically specific documentation?
答案：B
解題說明：
The findings create a strong clarification opportunity for hepatic encephalopathy. Cirrhosis, altered mental status, asterixis, elevated ammonia, and improvement with lactulose collectively support an encephalopathic process related to hepatic dysfunction.
The CDI specialist should not independently diagnose hepatic encephalopathy from the findings. Instead, the physician should be asked to clarify the condition represented by the documented phrase "altered mental status due to liver disease." Hepatic encephalopathy is clinically more specific than a nonspecific symptom such as altered mental status and has a distinct ICD-10-CM classification. Elevated ammonia alone is not sufficient to establish the diagnosis because ammonia levels do not always correlate directly with the severity of encephalopathy. The entire clinical picture must be considered.
Dementia generally represents a chronic neurocognitive disorder and does not adequately explain the acute presentation. Alcohol withdrawal requires an appropriate history of cessation or reduction plus characteristic withdrawal manifestations. Metabolic acidosis concerns acid-base physiology and is not supported by the described findings.
This is an example of CDI moving documentation from a nonspecific symptom to a clinically meaningful diagnosis without directing the provider to a predetermined answer.
CCDS Reference Topics: Hepatic encephalopathy; cirrhosis; neurologic manifestations; clinical indicators; documentation specificity.
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問題 #98
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