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| Section | Weight | Objectives |
|---|---|---|
| Communication skills | 9.17% | - CDI and coding roles and interdisciplinary collaboration - Physician education and effective communication |
| Official Guidelines for Coding and Reporting | 14.17% | - Coding guidelines, AHA Coding Clinic, HACs, and POA indicators - Principal and secondary diagnosis assignment |
| Anatomy and physiology, pathophysiology, pharmacology, and medical terminology | 19.17% | - Anatomy, physiology, pathophysiology, pharmacology, and terminology - Clinical conditions and clinical indicators |
| Medical record documentation | 19.17% | - Documentation clarification and compliant physician queries - Documentation requirements and diagnosis or procedure code assignment |
| Professionalism, ethics, and compliance | 9.17% | - Confidentiality, DRG compliance, and ethical CDI practices - Query compliance, DRG creep, and audit risks |
| Impact of reportable diagnoses on quality of care | 8.33% | - Mortality, severity of illness, and risk of mortality - Quality metrics, reporting programs, and financial impact |
| Healthcare facility CDI program analysis | 8.33% | - Data analysis, forecasting, and performance measurement - CDI productivity, provider response, CMI, and program metrics |
| Healthcare regulations, reimbursement, and documentation requirements related to the IPPS | 12.5% | - CC/MCC, CMI, Medicare contractors, and compliance - IPPS, MS-DRGs, reimbursement, and medical necessity |
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NEW QUESTION # 29
A CDI manager finds that cardiology providers receive repeated queries for heart-failure acuity and type.
Which educational intervention is MOST appropriate?
Answer: A
Explanation:
The most effective intervention is targeted, service-line-specific physician education based on actual documentation trends and clinically relevant examples.
Repeated queries for the same issue usually indicate a systematic documentation opportunity rather than isolated provider mistakes. Education should therefore show cardiologists how documentation of heart-failure type-such as systolic, diastolic, or combined-and acuity-acute, chronic, or acute on chronic- communicates the patient's clinical condition more precisely.
Using deidentified examples from the service line makes the education immediately relevant and enables physicians to recognize which clinical circumstances frequently generate clarification. Aggregate query data can demonstrate where documentation gaps occur without criticizing individual providers.
Sending an entire code book places coding responsibility on physicians and is unlikely to change documentation behavior. Stopping queries leaves unresolved clinical ambiguity. Framing the education around reduced reimbursement is also inappropriate because the goal of CDI education is accurate clinical representation, not coaching physicians toward higher-paying diagnoses.
The 2026 ACDIS/AHIMA query guidance identifies accurate representation of the patient's clinical status as the underlying purpose of CDI clarification.
CCDS Reference Topics: Physician education; communication; heart-failure specificity; query trend analysis.
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NEW QUESTION # 30
A patient with metastatic lung cancer is admitted solely for treatment of anemia caused by chemotherapy. The patient receives packed red blood cells and no treatment directed at the malignancy. Which diagnosis should be sequenced first?
Answer: A
Explanation:
When an admission is specifically for treatment of anemia associated with an adverse effect of chemotherapy or immunotherapy, and treatment is directed only at the anemia, the anemia diagnosis is sequenced first.
The FY 2026 ICD-10-CM Official Guidelines distinguish chemotherapy-related anemia from anemia caused directly by the malignancy. For chemotherapy-associated anemia, the anemia code is sequenced first, followed by the appropriate neoplasm code and the applicable adverse-effect code for the antineoplastic drug.
This differs significantly from anemia associated with the malignancy itself. If the patient is admitted solely to manage anemia caused by the malignancy, the malignancy is sequenced first, followed by the anemia-in- neoplastic-disease code.
The adverse-effect code is required to explain the medication-related cause, but it is not sequenced before the manifestation in this scenario because adverse-effect coding follows the nature of the adverse effect first.
For CDI specialists, accurate documentation of the cause of anemia-malignancy, chemotherapy, bleeding, chronic disease, nutritional deficiency, or another condition-is therefore essential because etiologic specificity can directly change sequencing.
CCDS Reference Topics: Chemotherapy adverse effects; anemia; neoplasm coding; principal diagnosis; sequencing.
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NEW QUESTION # 31
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: A
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 # 32
At discharge, the physician documents, "Possible gram-negative pneumonia." No later documentation rules out the condition. How should the diagnosis generally be handled for an inpatient admission?
Answer: B
Explanation:
In the inpatient hospital setting, an uncertain diagnosis documented at discharge using terminology such as possible, probable, suspected, likely, questionable, compatible with, or consistent with may generally be coded as though the condition existed or was established.
Therefore, "possible gram-negative pneumonia" may be coded in accordance with the inpatient uncertain- diagnosis guideline when it remains the final diagnostic conclusion.
The rationale is that inpatient diagnostic evaluation and treatment frequently occur before absolute confirmation is available, and the patient may have been managed as though the suspected disease were present.
This rule is materially different from outpatient coding, where uncertain diagnoses are generally not coded as established and the documented signs, symptoms, or confirmed conditions are reported instead.
The presence of the uncertain terminology alone does not mandate a query. A query would be appropriate if documentation is contradictory, if the diagnosis is clinically unsupported, or if another documentation issue prevents correct code assignment.
CDI specialists need to recognize this inpatient-specific rule because unnecessary queries for "possible" or
"probable" diagnoses can create physician burden without improving coding accuracy.
CCDS Reference Topics: Uncertain inpatient diagnoses; discharge documentation; pneumonia; inpatient versus outpatient coding.
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NEW QUESTION # 33
A CDI specialist submits a neutral query regarding possible acute blood loss anemia. The physician answers
"clinically unable to determine." The CDI specialist believes documenting the diagnosis would increase reimbursement substantially. What is the MOST appropriate next action?
Answer: C
Explanation:
The provider's response should be respected unless new information or a genuine unresolved documentation issue creates a legitimate reason for additional clarification.
"Clinically unable to determine" is an acceptable professional conclusion when the available evidence does not permit the provider to confidently establish a diagnosis. A CDI specialist must not continue sending essentially the same query simply because a different response would produce more favorable reimbursement.
Likewise, CDI cannot alter the provider's response or instruct coding personnel to assign a diagnosis that the provider declined to establish.
The 2026 ACDIS/AHIMA Guidelines for Achieving a Compliant Query Practice supersede all previous versions and serve as the current foundational resource for query processes. The query process is intended to improve the accuracy, completeness, and integrity of documentation-not to secure a predetermined financial result.
A legitimate follow-up could occur if new laboratory values, operative findings, transfusion information, pathology, or other material information emerges after the original response and creates a materially different clarification question.
Professional CDI practice requires balancing clinical advocacy with provider autonomy, ethical conduct, and regulatory compliance.
CCDS Reference Topics: Provider query responses; ethical CDI practice; repeated queries; provider independence; compliance.
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NEW QUESTION # 34
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