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| Section | Weight | Objectives |
|---|---|---|
| Anatomy and physiology, pathophysiology, pharmacology, and medical terminology | 19.17% | - HIV infections - Diseases and disorders of the skin, subcutaneous tissue, and breast - Injuries, poisonings, and toxic effects of drugs - Medications as clinical indicators - Diseases and disorders of the hepatobiliary system - Diagnostic tests as clinical indicators - Myeloproliferative diseases and disorders and poorly differentiated neoplasms - Standard medical abbreviations - Clinical indicators and query opportunities by Major Diagnostic Category - Diseases and disorders of the circulatory system - Diseases and disorders of the blood and blood-forming organs and immunological disorders - Diseases and disorders of the kidney and urinary tract - Mental diseases and disorders - Diseases and disorders of the musculoskeletal system - Diseases and disorders of the respiratory system - Endocrine, nutritional, and metabolic diseases and disorders - Diseases and disorders of the nervous system - Diseases and disorders of the digestive system - Pharmaceuticals and disease processes - Alcohol/drug use and alcohol/drug-induced organic brain disorders - Infectious and parasitic diseases |
| Communication skills | 9.17% | - Roles and responsibilities of coders working with CDI departments - Educational presentations for healthcare departments and administration - Reconciling CDI working DRGs with final coded DRGs - Effective and non-confrontational physician communication - Physician education forms and tools - Roles and responsibilities of CDI specialists - Verbal versus written physician communication |
| Healthcare regulations, reimbursement, and documentation requirements related to the IPPS | 12.5% | - Case mix index (CMI) - Medicare contractors and their impact on CDI - Medicare Severity Diagnosis Related Groups (MS-DRGs) - Complication/comorbidity (CC) - Documentation and medical necessity of setting - Major complication/comorbidity (MCC) - Inpatient admission criteria and CMS Two-Midnight Rule - Documentation impact on IPPS reimbursement - 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 |
| Impact of reportable diagnoses on quality of care | 8.33% | - Hospital Inpatient Quality Reporting Program - CDI impact on Hospital Value-Based Purchasing - Healthcare-associated infections and complication codes - Hospital-Acquired Condition Reduction Program - Hospital Readmissions Reduction Program - Patient Safety Indicators - Hospital Value-Based Purchasing - 30-day mortality measures - Documentation and code assignment impact on mortality index - Coded data elements affecting Patient Safety Indicators - Quality data from record abstraction and claims data - Mortality reviews and observed/expected ratios |
| Official Guidelines for Coding and Reporting | 14.17% | - Present on admission indicators - AHA Coding Clinic - Official Guidelines for Coding and Reporting updates - Secondary diagnosis assignment - Working DRG assignment for multiple diagnoses - Discharge dispositions and transfers - Coding guidelines for principal diagnosis selection - Hospital-acquired conditions - Principal diagnosis assignment |
| Medical record documentation | 19.17% | - When a physician query is warranted - Documentation requiring clarification - Addressing diagnoses without clinical support - Physician query formats - Situations in which queries are not appropriate - Translating clinical indicators into compliant queries - Clinical indicators - ACDIS/AHIMA Guidelines for Achieving a Compliant Query Practice - Health record elements used for diagnosis and procedure code assignment - Provider role and diagnosis code assignment - Types of physician queries - Compliant and noncompliant queries |
| Professionalism, ethics, and compliance | 9.17% | - CDI department goals beyond reimbursement - DRG compliance initiatives - Leading queries - Potential DRG creep - Compliance risks indicated by PEPPER - Medical record confidentiality |
| Healthcare facility CDI program analysis | 8.33% | - Case mix index (CMI) - CC/MCC capture - Hospital-specific financial data - Tracking and trending physician, department, and hospital performance - CDI specialist productivity metrics - Hospital Value-Based Purchasing measures - Publicly reported data - PEPPER data - Patient Safety Indicators - Physician performance measurement - Severity of illness and risk of mortality - Provider response rates - High-frequency DRGs - Basic computer and software application skills - CDI program forecasting |
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NEW QUESTION # 48
A patient is admitted with pneumonia. On hospital day 3, the patient deteriorates and the physician documents that sepsis developed after admission as a consequence of the pneumonia. Which diagnosis is generally sequenced first?
Answer: A
Explanation:
When a patient is admitted with a localized infection and sepsis develops after admission, the localized infection is generally sequenced as the principal diagnosis, followed by the appropriate sepsis code.
The FY 2026 ICD-10-CM Official Guidelines explicitly distinguish this circumstance from cases in which both the localized infection and sepsis are present on admission. When sepsis develops only after admission, the localized infection responsible for the original hospitalization remains principal.
Therefore, pneumonia is sequenced first in this scenario.
If the patient subsequently develops acute organ dysfunction related to sepsis and the provider documents severe sepsis, additional severe-sepsis and organ-dysfunction codes are assigned as appropriate. The severe- sepsis code cannot itself serve as principal diagnosis.
This question demonstrates why CDI specialists must clarify timing. Simply seeing both "pneumonia" and
"sepsis" in a discharge summary is insufficient to determine correct sequencing when the onset relationship is unclear.
The POA status of sepsis also becomes relevant because documentation indicates that it developed after inpatient admission.
CCDS Reference Topics: Sepsis; pneumonia; sequencing; timing; POA; principal diagnosis.
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NEW QUESTION # 49
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 # 50
A patient has a history of a type 2 MI 30 days ago. The patient is admitted for chest pain which is determined to be an NSTEMI. Which of the following diagnosis(es) should be coded to identify the working MS-DRG?
Answer: A
Explanation:
The current NSTEMI is the acute condition driving the admission. The prior type 2 myocardial infarction occurred 30 days earlier, placing it beyond the ICD-10-CM four-week acute-MI reporting window. The Official Guidelines state that category I21 codes may continue to be reported while an MI is four weeks old or less; after that period, an aftercare code may be appropriate when continued MI-related care is being provided, or I25.2 may describe an old/healed MI when applicable.
There is an additional reason not to select a "subsequent MI" answer. Category I22 is restricted to qualifying subsequent type 1 or unspecified acute myocardial infarctions occurring within four weeks of the initial qualifying MI. Type 2 MI is classified to I21.A1 rather than I22.
Therefore, the previous type 2 MI does not support selection of a subsequent-MI option in this 30-day scenario. The active NSTEMI is the diagnosis relevant to the working MS-DRG. "Initial encounter" in answer B is exam terminology rather than an ICD-10-CM seventh-character designation for MI, but B is clearly the intended correct choice.
CCDS Reference Topics: Official Guidelines-acute myocardial infarction; working MS-DRG; circulatory disorders.
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NEW QUESTION # 51
Each MS-DRG has a relative weight (RW). RW is primarily associated with which of the following?
Answer: D
Explanation:
An MS-DRG relative weight is primarily a measure of relative resource consumption. CMS explains that each MS-DRG is assigned a payment weight representing the average resources required to treat cases in that MS- DRG relative to the average resources required for cases across all DRGs.
A relative weight greater than 1.0 generally represents a case group expected to consume more resources than the overall Medicare inpatient average, whereas a weight below 1.0 reflects comparatively lower expected resource utilization. CMS recalibrates MS-DRG relative weights periodically using national cost and claims information.
Severity of illness often correlates with resource consumption because clinically complex patients commonly require additional diagnostics, monitoring, interventions, medications, procedures, and length of stay.
Nevertheless, severity of illness is not itself the definition of relative weight.
Hospital quality measures are evaluated through separate quality programs. Likewise, an individual hospital's billed charges do not directly define the MS-DRG relative weight assigned nationally, although standardized cost and charge data contribute to CMS's broader methodology for recalibrating weights.
Understanding relative weight is essential for CDI because documentation affects code and MS-DRG assignment, while the MS-DRG's relative weight influences the standardized IPPS payment calculation.
CCDS Reference Topics: MS-DRG relative weight; IPPS methodology; resource utilization; reimbursement fundamentals.
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NEW QUESTION # 52
A patient with type 2 diabetes mellitus is admitted with stage 4 chronic kidney disease. The physician documents both conditions but does not explicitly state that the CKD is caused by diabetes. No documentation indicates that the conditions are unrelated. Which of the following is the MOST appropriate coding approach?
Answer: A
Explanation:
ICD-10-CM permits a presumed causal relationship between diabetes mellitus and certain conditions indexed under "diabetes, with," including chronic kidney disease. Therefore, when diabetes and CKD are both documented and the provider has not specifically indicated that they are unrelated, the diabetes-with-CKD combination code is assigned together with an additional code identifying the CKD stage.
For type 2 diabetes, diabetic CKD is classified to E11.22, while an N18.- code identifies the documented CKD stage. In this scenario, stage 4 CKD would be additionally represented by the appropriate stage-specific N18 code.
A query is not routinely necessary simply to obtain wording such as "diabetic CKD" when the classification itself establishes the presumed relationship. However, clarification would be appropriate if documentation explicitly states another unrelated etiology or contains contradictory information.
This distinction is important for CDI because excessive querying can create unnecessary provider burden.
CDI specialists must understand which diagnostic relationships require explicit provider linkage and which are established through ICD-10-CM conventions.
The FY 2026 Official Guidelines remain applicable to discharges through September 30, 2026.
CCDS Reference Topics: Diabetes; CKD; presumed causal relationships; combination codes; coding conventions.
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NEW QUESTION # 53
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