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| Section | Weight | Objectives |
|---|---|---|
| Medical record documentation | 19.17% | - ACDIS/AHIMA Guidelines for Achieving a Compliant Query Practice - Provider role and diagnosis code assignment - Clinical indicators - When a physician query is warranted - Types of physician queries - Documentation requiring clarification - Translating clinical indicators into compliant queries - Situations in which queries are not appropriate - Addressing diagnoses without clinical support - Health record elements used for diagnosis and procedure code assignment - Compliant and noncompliant queries - Physician query formats |
| Healthcare regulations, reimbursement, and documentation requirements related to the IPPS | 12.5% | - Principal diagnosis and medical necessity - Complication/comorbidity (CC) - Documentation and medical necessity of setting - Medical staff and clinical staff documentation responsibilities - Major complication/comorbidity (MCC) - Coding and billing practices vulnerable to denial - Case mix index (CMI) - Inpatient admission criteria and CMS Two-Midnight Rule - Medicare Severity Diagnosis Related Groups (MS-DRGs) - Documentation impact on IPPS reimbursement - IPPS and its updates and revisions - Medicare contractors and their impact on CDI |
| Communication skills | 9.17% | - Educational presentations for healthcare departments and administration - Effective and non-confrontational physician communication - Roles and responsibilities of CDI specialists - Verbal versus written physician communication - Physician education forms and tools - Reconciling CDI working DRGs with final coded DRGs - Roles and responsibilities of coders working with CDI departments |
| Official Guidelines for Coding and Reporting | 14.17% | - Present on admission indicators - Discharge dispositions and transfers - AHA Coding Clinic - Official Guidelines for Coding and Reporting updates - Working DRG assignment for multiple diagnoses - Principal diagnosis assignment - Hospital-acquired conditions - Coding guidelines for principal diagnosis selection - Secondary diagnosis assignment |
| Anatomy and physiology, pathophysiology, pharmacology, and medical terminology | 19.17% | - Diseases and disorders of the nervous system - Myeloproliferative diseases and disorders and poorly differentiated neoplasms - Diseases and disorders of the musculoskeletal system - HIV infections - Mental diseases and disorders - Diseases and disorders of the blood and blood-forming organs and immunological disorders - Pharmaceuticals and disease processes - Standard medical abbreviations - Injuries, poisonings, and toxic effects of drugs - Diseases and disorders of the kidney and urinary tract - Diseases and disorders of the respiratory system - Diseases and disorders of the circulatory system - Alcohol/drug use and alcohol/drug-induced organic brain disorders - Diseases and disorders of the digestive system - Diagnostic tests as clinical indicators - Endocrine, nutritional, and metabolic diseases and disorders - Medications as clinical indicators - Diseases and disorders of the skin, subcutaneous tissue, and breast - Diseases and disorders of the hepatobiliary system - Infectious and parasitic diseases - Clinical indicators and query opportunities by Major Diagnostic Category |
| Healthcare facility CDI program analysis | 8.33% | - Hospital Value-Based Purchasing measures - CDI program forecasting - PEPPER data - Basic computer and software application skills - Severity of illness and risk of mortality - CC/MCC capture - CDI specialist productivity metrics - Patient Safety Indicators - Publicly reported data - Case mix index (CMI) - Physician performance measurement - Hospital-specific financial data - Provider response rates - High-frequency DRGs - Tracking and trending physician, department, and hospital performance |
| Impact of reportable diagnoses on quality of care | 8.33% | - Hospital Readmissions Reduction Program - Hospital Inpatient Quality Reporting Program - Coded data elements affecting Patient Safety Indicators - Hospital-Acquired Condition Reduction Program - Documentation and code assignment impact on mortality index - Hospital Value-Based Purchasing - 30-day mortality measures - Patient Safety Indicators - Healthcare-associated infections and complication codes - Mortality reviews and observed/expected ratios - CDI impact on Hospital Value-Based Purchasing - Quality data from record abstraction and claims data |
| Professionalism, ethics, and compliance | 9.17% | - Medical record confidentiality - DRG compliance initiatives - Leading queries - Potential DRG creep - Compliance risks indicated by PEPPER - CDI department goals beyond reimbursement |
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NEW QUESTION # 41
Two MS-DRGs have relative weights of 0.85 and 2.10. Which statement is MOST accurate?
Answer: D
Explanation:
An MS-DRG relative weight principally represents relative expected resource consumption. Therefore, a DRG with a relative weight of 2.10 is associated with greater average resource intensity than one with a relative weight of 0.85.
The weight does not determine the hospital's billed charges, nor is it a direct mortality score. Clinically complex patients may often fall into higher-weight DRGs because they require more resources, but resource intensity, severity of illness, and risk of mortality are conceptually distinct.
The relative weight contributes to IPPS payment calculations when multiplied through the applicable standardized-payment methodology and adjusted by hospital-specific factors and other payment rules.
CMS publishes current MS-DRG weighting factors as part of the FY 2026 IPPS Final Rule materials.
For CDI professionals, understanding relative weight helps explain why accurate diagnoses and procedures can influence reimbursement. However, reimbursement consequences must never become the justification for obtaining unsupported documentation. The objective remains accurate representation of the patient's clinical condition and resources required.
CCDS Reference Topics: Relative weight; resource consumption; IPPS; MS-DRG payment; severity concepts.
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NEW QUESTION # 42
A patient's baseline creatinine is 1.0 mg/dL. Following prolonged hypotension, creatinine rises to 3.8 mg/dL.
Urinalysis demonstrates granular casts, and the nephrologist documents "acute renal failure" but does not specify the underlying renal lesion. Which condition would be MOST appropriate to consider in a clinically supported clarification query?
Answer: B
Explanation:
The clinical pattern supports consideration of acute tubular necrosis (ATN) as a clarification opportunity.
Prolonged hypotension can cause renal ischemia severe enough to injure tubular epithelial cells. A substantial acute creatinine increase and granular or "muddy brown" casts are classic clinical findings associated with ATN.
The provider has already documented acute renal failure, so the purpose of the query would be to clarify the underlying type of acute kidney injury when clinically appropriate-not to create AKI from laboratory data alone.
Stage 5 chronic kidney disease requires evidence of chronic, persistent severe renal dysfunction and cannot be inferred from an acute creatinine rise following hypotension. Nephrotic syndrome is characterized principally by substantial proteinuria, hypoalbuminemia, edema, and other findings not described here. Pyelonephritis would ordinarily require evidence of upper urinary infection.
A CDI specialist should review the complete clinical record, including baseline renal function, hemodynamic course, nephrology notes, urinalysis, fluid management, nephrotoxic exposures, and renal replacement therapy when applicable.
The CCDS competency framework includes renal failure, laboratory interpretation, and recognition of clinically supported opportunities for diagnostic specificity.
CCDS Reference Topics: Acute kidney injury; acute tubular necrosis; renal pathophysiology; clinical indicators; diagnostic specificity.
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NEW QUESTION # 43
An operative report states that the surgeon performed an excisional debridement of a heel wound. The report documents removal of necrotic tissue but does not identify the deepest tissue level removed. What should the CDI specialist clarify?
Answer: D
Explanation:
For excisional debridement, documentation of the deepest tissue level actually removed is essential for accurate ICD-10-PCS procedure assignment. Relevant levels may include skin, subcutaneous tissue, fascia, muscle, or bone.
The presence of a deep wound does not establish that debridement reached the deepest anatomical layer visible in the wound. For example, a wound may extend to muscle while the physician removes only necrotic subcutaneous tissue. Coding must reflect the body part and tissue actually debrided rather than the overall depth of the wound.
Therefore, the CDI specialist should clarify what tissue was excised. Other procedural elements may already be supported by the operative documentation, including the excisional nature of the procedure.
The number of instruments or duration of anesthesia does not determine the applicable body-part value.
Similarly, administrative details have no bearing on procedural specificity.
CDI specialists working with surgical records must understand the distinction between wound description and procedure performance. Accurate procedural documentation can affect ICD-10-PCS coding and ultimately MS-DRG assignment, particularly when an operating-room procedure influences grouper logic.
The CCDS competency framework includes medical-record review and coding/payment implications of inpatient procedures.
CCDS Reference Topics: Excisional debridement; ICD-10-PCS; tissue depth; operative documentation.
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NEW QUESTION # 44
What type of query is needed to compliantly address a scenario in which clinical indicators of a diagnosis exist, but for which no diagnosis has been documented in the medical record?
Answer: D
Explanation:
A multiple-choice query is appropriate when clinical indicators support the possibility of a condition but the diagnosis itself has not yet been documented. The query may present clinically reasonable diagnostic choices supported by the patient's record while also allowing an alternative response such as "other, please specify" or an inability to determine.
A yes/no query is not the appropriate format for introducing a new, previously undocumented diagnosis.
AHIMA/ACDIS guidance has specifically distinguished this situation from circumstances where yes/no clarification may be used for an already documented condition, POA determination, cause-and-effect clarification, or similar defined purposes.
A clinical-validation query addresses the opposite problem: a diagnosis is already documented, but the health record appears to lack sufficient clinical support for that diagnosis. Therefore, option C does not match the scenario.
A cause-and-effect query would be appropriate when two documented conditions require clarification of their relationship, not when the fundamental issue is the absence of a diagnosis.
Current AHIMA/ACDIS guidance continues to permit multiple-choice queries supported by relevant clinical indicators and emphasizes neutral wording.
CCDS Reference Topics: Compliant query formats; missing diagnosis; clinical validation; nonleading queries.
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NEW QUESTION # 45
When reviewing a patient's chart in the ICU, a CDI specialist determines a query needs to be placed. As the query is being written, the attending physician is leaving the patient's room after completing rounds. Which of the following is the BEST action to take?
Answer: B
Explanation:
A verbal query is the most efficient and appropriate action because the responsible physician is immediately available and the documentation gap has already been identified. CDI practice is not limited to written or electronic queries; verbal clarification is an accepted communication method when conducted compliantly.
The CDI specialist should present the relevant clinical indicators objectively and ask for clarification without directing the physician toward a preferred diagnosis. The conversation should remain clinically focused and must not mention reimbursement, MS-DRG impact, quality scoring, or other incentives.
Importantly, verbal does not mean informal or undocumented. Current query standards require organizations to maintain an auditable query process. Historically, ACDIS/AHIMA guidance has specifically required the essence of verbal queries to be memorialized, including the reason for clarification and relevant clinical indicators. The 2026 ACDIS/AHIMA Guidelines for Achieving a Compliant Query Practice supersede previous versions and remain the current foundational industry standard for query practice.
Waiting unnecessarily could delay clarification and interfere with concurrent CDI workflow. Since the physician is available, direct professional communication is preferable.
CCDS Reference Topics: Communication skills; verbal queries; concurrent CDI review; compliant query practice.
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NEW QUESTION # 46
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