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| Section | Weight | Objectives |
|---|---|---|
| Professionalism, ethics, and compliance | 9.17% | - Medical record confidentiality - Compliance risks indicated by PEPPER - DRG compliance initiatives - Potential DRG creep - CDI department goals beyond reimbursement - Leading queries |
| Healthcare facility CDI program analysis | 8.33% | - Hospital-specific financial data - CC/MCC capture - Hospital Value-Based Purchasing measures - Physician performance measurement - CDI program forecasting - Case mix index (CMI) - Basic computer and software application skills - PEPPER data - High-frequency DRGs - Patient Safety Indicators - Severity of illness and risk of mortality - Tracking and trending physician, department, and hospital performance - CDI specialist productivity metrics - Provider response rates - Publicly reported data |
| Communication skills | 9.17% | - Effective and non-confrontational physician communication - Educational presentations for healthcare departments and administration - Roles and responsibilities of CDI specialists - Reconciling CDI working DRGs with final coded DRGs - Roles and responsibilities of coders working with CDI departments - Verbal versus written physician communication - Physician education forms and tools |
| Medical record documentation | 19.17% | - Compliant and noncompliant queries - ACDIS/AHIMA Guidelines for Achieving a Compliant Query Practice - Situations in which queries are not appropriate - Documentation requiring clarification - When a physician query is warranted - Addressing diagnoses without clinical support - Physician query formats - Provider role and diagnosis code assignment - Clinical indicators - Types of physician queries - Translating clinical indicators into compliant queries - Health record elements used for diagnosis and procedure code assignment |
| Official Guidelines for Coding and Reporting | 14.17% | - Discharge dispositions and transfers - Coding guidelines for principal diagnosis selection - Official Guidelines for Coding and Reporting updates - Principal diagnosis assignment - Secondary diagnosis assignment - AHA Coding Clinic - Working DRG assignment for multiple diagnoses - Hospital-acquired conditions - Present on admission indicators |
| Anatomy and physiology, pathophysiology, pharmacology, and medical terminology | 19.17% | - Pharmaceuticals and disease processes - Injuries, poisonings, and toxic effects of drugs - Diagnostic tests as clinical indicators - Standard medical abbreviations - Medications as clinical indicators - Diseases and disorders of the kidney and urinary tract - Diseases and disorders of the musculoskeletal system - Endocrine, nutritional, and metabolic diseases and disorders - Diseases and disorders of the nervous system - Diseases and disorders of the digestive system - Diseases and disorders of the blood and blood-forming organs and immunological disorders - Infectious and parasitic diseases - Alcohol/drug use and alcohol/drug-induced organic brain disorders - HIV infections - Myeloproliferative diseases and disorders and poorly differentiated neoplasms - Mental diseases and disorders - Diseases and disorders of the respiratory system - Diseases and disorders of the skin, subcutaneous tissue, and breast - Diseases and disorders of the hepatobiliary system - Diseases and disorders of the circulatory system - Clinical indicators and query opportunities by Major Diagnostic Category |
| Impact of reportable diagnoses on quality of care | 8.33% | - Hospital Readmissions Reduction Program - Healthcare-associated infections and complication codes - Documentation and code assignment impact on mortality index - Hospital-Acquired Condition Reduction Program - CDI impact on Hospital Value-Based Purchasing - Mortality reviews and observed/expected ratios - Hospital Value-Based Purchasing - Hospital Inpatient Quality Reporting Program - Coded data elements affecting Patient Safety Indicators - Patient Safety Indicators - Quality data from record abstraction and claims data - 30-day mortality measures |
| Healthcare regulations, reimbursement, and documentation requirements related to the IPPS | 12.5% | - Medicare Severity Diagnosis Related Groups (MS-DRGs) - Principal diagnosis and medical necessity - Major complication/comorbidity (MCC) - Medicare contractors and their impact on CDI - Case mix index (CMI) - Documentation impact on IPPS reimbursement - Medical staff and clinical staff documentation responsibilities - Documentation and medical necessity of setting - Inpatient admission criteria and CMS Two-Midnight Rule - Coding and billing practices vulnerable to denial - IPPS and its updates and revisions - Complication/comorbidity (CC) |
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146. Frage
A 34-year-old female was admitted from a group home with uncontrolled diabetes. A CDI specialist must query to specify the patient's mental incapacity since it makes management of the diabetes more difficult.
Which of the following terminology recognized by ICD-10-CM could result in the assignment of a comorbid condition?
Antwort: C
Begründung:
Severe intellectual disability is recognized ICD-10-CM terminology and maps to F72, Severe intellectual disabilities. The other phrases are not equivalent standardized ICD-10-CM diagnostic terminology.
This distinction is highly relevant to CDI. Terms used conversationally in the clinical record do not necessarily provide sufficient specificity or map cleanly to reportable ICD-10-CM diagnoses. When a patient's cognitive or developmental condition affects treatment, monitoring, self-management, nursing requirements, or the complexity of care, the CDI specialist should seek clinically appropriate provider documentation using recognized diagnostic terminology.
For FY 2026 MS-DRG logic, CMS identifies F72 as a CC, meaning it can qualify as a complication
/comorbidity when it meets secondary-diagnosis reporting requirements. That does not mean the CDI specialist should query merely for reimbursement impact. The query must be clinically justified by the record and should allow the provider to determine the correct diagnosis.
"Severe mental challenge," "acute mental incapacity," and "acute intellectual disability" do not represent the same codable disease classification.
CCDS Reference Topics: Medical terminology; mental/behavioral and neurodevelopmental disorders; CC recognition; clinically supported query opportunities.
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147. Frage
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?
Antwort: A
Begründung:
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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148. Frage
A CDI specialist reviews a prior hospitalization and finds that the patient previously had chronic systolic heart failure. During the current admission, the provider documents only "history of CHF," although the patient remains on long-term heart-failure therapy. What is the BEST approach?
Antwort: B
Begründung:
Prior-encounter information may provide valuable clinical context, but it should not automatically be imported as a current reportable diagnosis without considering whether the condition remains active and relevant to the present encounter.
Here, a prior diagnosis of chronic systolic heart failure, ongoing heart-failure therapy, and ambiguous current wording such as "history of CHF" create a reasonable opportunity to clarify the patient's current heart-failure status if that information is clinically relevant.
The CDI specialist should not independently carry forward the previous diagnosis or escalate it to acute heart failure. Conversely, rigidly ignoring reliable prior clinical information can prevent identification of legitimate documentation gaps.
The 2026 ACDIS/AHIMA query guidance specifically includes the role of prior encounters as part of its updated query-practice framework, while emphasizing compliant provider clarification and accurate representation of the current patient's clinical status.
A query should make clear which current clinical indicators support the need for clarification and should not imply that a previous diagnosis must automatically remain valid.
CCDS Reference Topics: Prior encounters; chronic conditions; heart failure; query practice; current- encounter documentation.
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149. Frage
The physician evaluates a postoperative wound infection but states, "I cannot clinically determine whether the infection was already developing at admission or began after admission." Which POA indicator MOST accurately reflects this provider determination?
Antwort: A
Begründung:
POA indicator W means the provider is clinically unable to determine whether the condition was present on admission. That is precisely what is documented in this scenario.
This must be distinguished from POA indicator U. U means the documentation is insufficient to determine POA status, whereas W reflects an actual clinical determination that the timing cannot be established even after appropriate assessment.
Indicator Y means the condition was present when the inpatient admission order occurred, while N means it was not present at that point.
This distinction matters because POA status contributes to CMS Hospital-Acquired Condition payment logic and hospital quality analyses. CDI specialists should attempt to obtain clarification when timing is unclear, but they must accept a legitimate provider determination that onset cannot clinically be established.
Not every ambiguous timeline should be forced into either Y or N. When clinical evidence truly cannot resolve the timing, W is an appropriate reporting outcome.
CMS maintains separate annual POA-exempt resources and HAC/POA coding information for the applicable fiscal year.
CCDS Reference Topics: POA indicators; W versus U; onset timing; HACs; inpatient coding.
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150. Frage
A patient develops chest pain and elevated troponins while receiving care in the emergency department. The physician diagnoses an NSTEMI. Several hours later, an inpatient admission order is written. How should the NSTEMI generally be considered for POA purposes?
Antwort: B
Begründung:
For POA reporting, "present on admission" refers to a condition present at the time the order for inpatient admission occurs. Conditions that develop during an outpatient encounter-including emergency-department, observation, or outpatient surgery care-before the inpatient admission order are generally considered POA when they are present at that inpatient admission point.
Therefore, the NSTEMI in this scenario is considered present on admission even though it developed after the patient physically arrived at the hospital.
This distinction is essential because hospital arrival and inpatient admission are not synonymous for POA purposes. A patient may spend hours in the ED or observation status before an inpatient order is entered.
The POA indicator applies to applicable principal and secondary diagnoses and is important to CMS's HAC payment provisions as well as quality analysis. A condition does not become hospital acquired merely because it arose somewhere on hospital premises before inpatient status began.
CDI specialists should clarify timing when the record does not establish whether a diagnosis existed before or after the inpatient admission order rather than relying solely on note timestamps or physical location.
The FY 2026 ICD-10-CM Official Guidelines contain the governing POA definitions and reporting rules.
CCDS Reference Topics: POA; emergency department; observation; timing of diagnosis; HAC payment logic.
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151. Frage
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