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| Section | Weight | Objectives |
|---|---|---|
| Medical record documentation | 19.17% | - Addressing diagnoses without clinical support - Situations in which queries are not appropriate - Health record elements used for diagnosis and procedure code assignment - Types of physician queries - Provider role and diagnosis code assignment - Compliant and noncompliant queries - Physician query formats - Documentation requiring clarification - Translating clinical indicators into compliant queries - ACDIS/AHIMA Guidelines for Achieving a Compliant Query Practice - When a physician query is warranted - Clinical indicators |
| Impact of reportable diagnoses on quality of care | 8.33% | - CDI impact on Hospital Value-Based Purchasing - 30-day mortality measures - Patient Safety Indicators - Coded data elements affecting Patient Safety Indicators - Healthcare-associated infections and complication codes - Hospital Value-Based Purchasing - Hospital Inpatient Quality Reporting Program - Hospital-Acquired Condition Reduction Program - Documentation and code assignment impact on mortality index - Quality data from record abstraction and claims data - Hospital Readmissions Reduction Program - Mortality reviews and observed/expected ratios |
| Professionalism, ethics, and compliance | 9.17% | - CDI department goals beyond reimbursement - Leading queries - Medical record confidentiality - Compliance risks indicated by PEPPER - Potential DRG creep - DRG compliance initiatives |
| Official Guidelines for Coding and Reporting | 14.17% | - Hospital-acquired conditions - Present on admission indicators - Coding guidelines for principal diagnosis selection - Working DRG assignment for multiple diagnoses - Secondary diagnosis assignment - Official Guidelines for Coding and Reporting updates - AHA Coding Clinic - Principal diagnosis assignment - Discharge dispositions and transfers |
| Healthcare regulations, reimbursement, and documentation requirements related to the IPPS | 12.5% | - Medicare Severity Diagnosis Related Groups (MS-DRGs) - Principal diagnosis and medical necessity - Medical staff and clinical staff documentation responsibilities - Complication/comorbidity (CC) - Documentation and medical necessity of setting - Major complication/comorbidity (MCC) - Medicare contractors and their impact on CDI - Coding and billing practices vulnerable to denial - Inpatient admission criteria and CMS Two-Midnight Rule - Documentation impact on IPPS reimbursement - Case mix index (CMI) - IPPS and its updates and revisions |
| Communication skills | 9.17% | - Effective and non-confrontational physician communication - Educational presentations for healthcare departments and administration - Verbal versus written physician communication - Roles and responsibilities of coders working with CDI departments - Physician education forms and tools - Reconciling CDI working DRGs with final coded DRGs - Roles and responsibilities of CDI specialists |
| Healthcare facility CDI program analysis | 8.33% | - Hospital Value-Based Purchasing measures - PEPPER data - CDI program forecasting - Hospital-specific financial data - Basic computer and software application skills - Provider response rates - Physician performance measurement - Severity of illness and risk of mortality - Patient Safety Indicators - Publicly reported data - High-frequency DRGs - CC/MCC capture - Tracking and trending physician, department, and hospital performance - Case mix index (CMI) - CDI specialist productivity metrics |
| Anatomy and physiology, pathophysiology, pharmacology, and medical terminology | 19.17% | - Diagnostic tests as clinical indicators - Diseases and disorders of the nervous system - Diseases and disorders of the kidney and urinary tract - Diseases and disorders of the hepatobiliary system - Myeloproliferative diseases and disorders and poorly differentiated neoplasms - Mental diseases and disorders - Diseases and disorders of the skin, subcutaneous tissue, and breast - Pharmaceuticals and disease processes - Medications as clinical indicators - Diseases and disorders of the musculoskeletal system - Diseases and disorders of the digestive system - Standard medical abbreviations - Diseases and disorders of the respiratory system - Alcohol/drug use and alcohol/drug-induced organic brain disorders - Injuries, poisonings, and toxic effects of drugs - Endocrine, nutritional, and metabolic diseases and disorders - 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 - Infectious and parasitic diseases - HIV infections |
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NEW QUESTION # 26
A physician responds to a clinically supported CDI query by stating that the proposed diagnosis does not apply and documents a different diagnosis supported by the patient's condition. What is the BEST action by the CDI specialist?
Answer: A
Explanation:
The CDI specialist should respect the provider's independent clinical judgment, provided the response clearly addresses the query and the resulting documentation is clinically coherent.
A query is a request for clarification-not a mechanism for compelling the provider to select CDI's preferred diagnosis. Physician disagreement is therefore not inherently a failed query. The provider may appropriately document another condition, rule out a suspected condition, or explain why the indicators have another clinical interpretation.
Repeatedly querying until a desired diagnosis appears creates serious compliance risk and can undermine the integrity of the documentation process. Escalation may be appropriate in defined circumstances-for example, unresolved contradictions, unanswered high-priority queries, or persistent clinical-validation issues-but should follow organizational policy and should not occur merely because CDI dislikes the provider's answer.
The 2026 ACDIS/AHIMA guidance is the current foundational query-practice standard and emphasizes compliant clarification across healthcare settings.
Effective CDI communication requires clinical knowledge, professional dialogue, and recognition that final diagnostic determinations belong to the responsible provider.
CCDS Reference Topics: Physician communication; query responses; provider independence; escalation; professional conduct.
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NEW QUESTION # 27
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: B
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 # 28
The attending physician documents morbid obesity. A registered dietitian documents a body mass index of
43.6 kg/m² in the nutritional assessment. Which of the following is the MOST accurate statement?
Answer: D
Explanation:
BMI is one of the explicit ICD-10-CM exceptions permitting code assignment from documentation by a clinician other than the provider responsible for establishing the diagnosis. Therefore, the BMI of 43.6 may be taken from the dietitian's documentation, while the associated diagnosis of morbid obesity is supported by the attending physician's documentation.
The FY 2026 Official Guidelines specifically identify BMI, pressure-ulcer stage, non-pressure ulcer depth, coma scale, NIH Stroke Scale, certain social determinants, laterality, blood alcohol level, and several other elements as information that may be documented by other qualified clinicians. However, the associated diagnosis, such as obesity, must be documented by the patient's provider.
Option C incorrectly gives the dietitian's BMI documentation authority to establish the obesity diagnosis itself. Option D imposes an unnecessary discharge-summary requirement; valid diagnoses may be supported by appropriate provider documentation elsewhere in the health record according to applicable coding rules.
For CDI specialists, the key distinction is between a diagnosis and a permissible clinical detail used to further characterize that diagnosis.
CCDS Reference Topics: BMI; non-provider documentation; obesity; medical-record review; coding documentation exceptions.
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NEW QUESTION # 29
The progress note on hospital day 2 of a patient's admission states that the patient got up from the bed to go to the bathroom just after housekeeping had mopped the floor. The patient slipped and fell onto the floor, sustaining a broken wrist. The diagnosis of a fractured wrist will:
Answer: B
Explanation:
The fracture occurred after inpatient admission as the result of a hospital fall, placing it within CMS's Hospital-Acquired Condition category for Falls and Trauma when the applicable fracture code is included in the HAC code list. CMS's FY 2026 MS-DRG Definitions Manual continues to identify qualifying fracture codes within HAC 05.
The fracture must still be coded; therefore, option D is incorrect. Because it clearly developed after admission, it would not appropriately receive POA indicator "U," which indicates insufficient documentation to determine whether the condition was present on admission.
For qualifying HAC diagnoses that are not POA, CMS payment logic prevents the hospital from receiving the higher MS-DRG payment that would otherwise result solely from the condition's CC/MCC status. Thus, option B expresses the intended payment effect.
This distinction is central to CDI practice: a hospital-acquired diagnosis does not disappear from the record or coding. It remains reportable for clinical and quality purposes, but certain qualifying HACs are treated differently in MS-DRG payment calculations.
CCDS Reference Topics: HACs; POA indicators; Falls and Trauma; MS-DRG payment adjustment.
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NEW QUESTION # 30
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 # 31
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