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| Section | Weight | Objectives |
|---|---|---|
| Topic 1: Anatomy and physiology, pathophysiology, pharmacology, and medical terminology | 19.17% | - Clinical conditions and clinical indicators - Anatomy, physiology, pathophysiology, pharmacology, and terminology |
| Topic 2: Healthcare facility CDI program analysis | 8.33% | - Data analysis, forecasting, and performance measurement - CDI productivity, provider response, CMI, and program metrics |
| Topic 3: Impact of reportable diagnoses on quality of care | 8.33% | - Quality metrics, reporting programs, and financial impact - Mortality, severity of illness, and risk of mortality |
| Topic 4: Communication skills | 9.17% | - Physician education and effective communication - CDI and coding roles and interdisciplinary collaboration |
| Topic 5: Official Guidelines for Coding and Reporting | 14.17% | - Coding guidelines, AHA Coding Clinic, HACs, and POA indicators - Principal and secondary diagnosis assignment |
| Topic 6: Healthcare regulations, reimbursement, and documentation requirements related to the IPPS | 12.5% | - IPPS, MS-DRGs, reimbursement, and medical necessity - CC/MCC, CMI, Medicare contractors, and compliance |
| Topic 7: Medical record documentation | 19.17% | - Documentation clarification and compliant physician queries - Documentation requirements and diagnosis or procedure code assignment |
| Topic 8: Professionalism, ethics, and compliance | 9.17% | - Query compliance, DRG creep, and audit risks - Confidentiality, DRG compliance, and ethical CDI practices |
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NEW QUESTION # 22
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 # 23
A patient has chronic gastroesophageal reflux disease listed in the past medical history. During the current hospitalization for bacterial pneumonia, GERD receives no clinical evaluation, treatment, diagnostic testing, increased nursing monitoring, or effect on length of stay. Which statement is MOST accurate?
Answer: A
Explanation:
A condition documented in the medical record does not automatically qualify as a reportable secondary diagnosis. For inpatient coding, additional diagnoses generally must be clinically significant during the current hospitalization. Qualifying significance includes clinical evaluation, therapeutic treatment, diagnostic procedures, an extended length of stay, or increased nursing care and/or monitoring.
Here, GERD is merely part of the patient's historical medical background and does not affect current management. Therefore, it generally should not be reported as an additional diagnosis solely because it appears in the past medical history.
Whether a diagnosis is classified as a CC or MCC is a separate issue. A condition must first satisfy applicable reporting requirements before its MS-DRG severity classification matters. CDI specialists should never encourage coding of clinically irrelevant historical conditions merely because they could affect reimbursement.
This principle protects the clinical integrity of coded data and prevents inappropriate inflation of disease burden. CDI review should focus on conditions that meaningfully describe the patient's current hospitalization, treatment requirements, clinical risk, and resource consumption.
CCDS Reference Topics: Reporting additional diagnoses; secondary-diagnosis criteria; medical-record review; resource utilization; coding compliance.
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NEW QUESTION # 24
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: D
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 # 25
A patient is admitted with fever and weakness. On hospital day 3, final blood cultures identify an infection that the physician documents was present at the time of admission. Which statement about present-on- admission status is MOST accurate?
Answer: C
Explanation:
A condition can be assigned present-on-admission status even when the definitive diagnosis is not made until later in the hospitalization. POA refers to whether the condition was present at the time the order for inpatient admission occurred, not the calendar date on which diagnostic confirmation became available.
This distinction is particularly relevant for infections, malignancies, fractures, acute vascular events, and other conditions whose definitive identification may require cultures, pathology, imaging, or additional diagnostic testing.
Therefore, a blood culture finalized on hospital day 3 does not automatically make the infection hospital acquired. The clinical record and provider documentation must establish whether the disease process was present at admission.
POA assignment applies to applicable principal and secondary diagnoses, not only the principal diagnosis.
CDI specialists should recognize unclear timing as a potential clarification opportunity because POA status can affect CMS Hospital-Acquired Condition payment logic and quality reporting.
The CCDS content outline expressly includes the basics of POA assignment and its impact on payment, as well as identification of CMS HACs.
CCDS Reference Topics: Present on admission; diagnosis timing; HACs; inpatient coding; quality reporting.
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NEW QUESTION # 26
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?
Answer: D
Explanation:
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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NEW QUESTION # 27
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