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| Section | Weight | Objectives |
|---|---|---|
| Topic 1: Anatomy and physiology, pathophysiology, pharmacology, and medical terminology | 19.17% | - Diseases and disorders of the skin, subcutaneous tissue, and breast - Injuries, poisonings, and toxic effects of drugs - Infectious and parasitic diseases - Diseases and disorders of the musculoskeletal system - Diseases and disorders of the blood and blood-forming organs and immunological disorders - Mental diseases and disorders - Diseases and disorders of the respiratory system - Diseases and disorders of the digestive system - Pharmaceuticals and disease processes - Medications as clinical indicators - Endocrine, nutritional, and metabolic diseases and disorders - Standard medical abbreviations - Diseases and disorders of the nervous system - Diseases and disorders of the circulatory system - Diseases and disorders of the kidney and urinary tract - Diagnostic tests as clinical indicators - Clinical indicators and query opportunities by Major Diagnostic Category - Myeloproliferative diseases and disorders and poorly differentiated neoplasms - Diseases and disorders of the hepatobiliary system - Alcohol/drug use and alcohol/drug-induced organic brain disorders - HIV infections |
| Topic 2: Impact of reportable diagnoses on quality of care | 8.33% | - Documentation and code assignment impact on mortality index - Coded data elements affecting Patient Safety Indicators - Quality data from record abstraction and claims data - Hospital-Acquired Condition Reduction Program - 30-day mortality measures - Mortality reviews and observed/expected ratios - Healthcare-associated infections and complication codes - Patient Safety Indicators - Hospital Inpatient Quality Reporting Program - CDI impact on Hospital Value-Based Purchasing - Hospital Readmissions Reduction Program - Hospital Value-Based Purchasing |
| Topic 3: Healthcare regulations, reimbursement, and documentation requirements related to the IPPS | 12.5% | - Case mix index (CMI) - Inpatient admission criteria and CMS Two-Midnight Rule - Medicare Severity Diagnosis Related Groups (MS-DRGs) - Documentation impact on IPPS reimbursement - Documentation and medical necessity of setting - Complication/comorbidity (CC) - Principal diagnosis and medical necessity - Medicare contractors and their impact on CDI - IPPS and its updates and revisions - Medical staff and clinical staff documentation responsibilities - Coding and billing practices vulnerable to denial - Major complication/comorbidity (MCC) |
| Topic 4: Medical record documentation | 19.17% | - When a physician query is warranted - Health record elements used for diagnosis and procedure code assignment - Clinical indicators - Types of physician queries - ACDIS/AHIMA Guidelines for Achieving a Compliant Query Practice - Documentation requiring clarification - Physician query formats - Addressing diagnoses without clinical support - Situations in which queries are not appropriate - Compliant and noncompliant queries - Translating clinical indicators into compliant queries - Provider role and diagnosis code assignment |
| Topic 5: Healthcare facility CDI program analysis | 8.33% | - Case mix index (CMI) - Severity of illness and risk of mortality - Publicly reported data - Physician performance measurement - Hospital-specific financial data - Hospital Value-Based Purchasing measures - Patient Safety Indicators - Provider response rates - CDI specialist productivity metrics - Basic computer and software application skills - CC/MCC capture - High-frequency DRGs - CDI program forecasting - PEPPER data - Tracking and trending physician, department, and hospital performance |
| Topic 6: Communication skills | 9.17% | - Effective and non-confrontational physician communication - Physician education forms and tools - Roles and responsibilities of CDI specialists - Roles and responsibilities of coders working with CDI departments - Verbal versus written physician communication - Reconciling CDI working DRGs with final coded DRGs - Educational presentations for healthcare departments and administration |
| Topic 7: Professionalism, ethics, and compliance | 9.17% | - Leading queries - DRG compliance initiatives - Potential DRG creep - Compliance risks indicated by PEPPER - Medical record confidentiality - CDI department goals beyond reimbursement |
| Topic 8: Official Guidelines for Coding and Reporting | 14.17% | - Principal diagnosis assignment - Hospital-acquired conditions - AHA Coding Clinic - Discharge dispositions and transfers - Official Guidelines for Coding and Reporting updates - Secondary diagnosis assignment - Working DRG assignment for multiple diagnoses - Present on admission indicators - Coding guidelines for principal diagnosis selection |
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NEW QUESTION # 43
A patient with sepsis has acute confusion, impaired attention, fluctuating mental status, and no focal neurologic findings. CT of the head is negative. The provider documents only "AMS secondary to infection." Which clarification would be MOST clinically appropriate?
Answer: D
Explanation:
The documented acute mental-status change associated with systemic infection creates a reasonable clarification opportunity for acute metabolic encephalopathy, assuming the complete clinical record supports that diagnosis.
Encephalopathy represents diffuse cerebral dysfunction arising from systemic, metabolic, toxic, hypoxic, infectious, or other causes. Acute confusion, impaired attention, fluctuating cognition, and absence of a focal lesion can support an encephalopathic process.
However, the CDI specialist cannot convert "altered mental status" into encephalopathy independently. The provider must determine whether the patient's presentation represents metabolic encephalopathy, delirium, medication effect, dementia, another neurologic condition, or simply a nonspecific symptom.
Chronic dementia does not fit the acute fluctuating pattern unless underlying dementia is separately documented. Cerebral infarction would generally require compatible focal neurologic findings and clinical or imaging evidence. Transient global amnesia typically presents with prominent acute memory disturbance rather than generalized encephalopathy.
A compliant query should include the mental-status findings, infectious process, relevant laboratory data, neurologic evaluation, treatment, and clinical course.
CCDS Reference Topics: Encephalopathy; altered mental status; infection; neurologic clinical indicators; diagnostic clarification.
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NEW QUESTION # 44
A patient has hypertension and acute on chronic diastolic heart failure documented during the same admission. The physician does not explicitly link the conditions and does not state that they are unrelated.
Which statement is MOST accurate?
Answer: A
Explanation:
ICD-10-CM generally presumes a causal relationship between hypertension and qualifying heart disease, including heart failure, when both are documented and the provider has not stated that they are unrelated.
The appropriate hypertensive heart-disease code is assigned together with an additional I50.- code identifying the specific heart-failure type and acuity.
The presumption is not limited to systolic heart failure. Diastolic and combined heart-failure diagnoses are included when they meet the applicable classification rules.
Therefore, a query solely asking the physician to state that hypertension caused the heart failure is generally unnecessary when both conditions are documented and no contradictory statement exists.
CDI should nevertheless query if the heart-failure type or acuity is unclear, documentation conflicts, or the provider explicitly indicates another relationship that affects classification.
Understanding presumed relationships is important because unnecessary queries consume physician time and create avoidable administrative work. CDI specialists must distinguish clinical relationships that require explicit provider linkage from those supplied by ICD-10-CM conventions.
CCDS Reference Topics: Hypertensive heart disease; heart failure; presumed causal relationship; coding conventions; query reduction.
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NEW QUESTION # 45
A patient is admitted with hypertension and stage 3b chronic kidney disease. The physician does not explicitly state that the CKD is caused by hypertension. The record contains no documentation indicating that the two conditions are unrelated. Which of the following is the MOST appropriate approach when assigning the working diagnoses?
Answer: B
Explanation:
ICD-10-CM presumes a causal relationship between hypertension and chronic kidney disease when both are documented, unless the provider specifically states that the conditions are unrelated. Therefore, the working coding logic should recognize hypertensive CKD and additionally identify the patient's CKD stage.
The FY 2026 Official Guidelines direct assignment of a code from category I12, Hypertensive chronic kidney disease, when hypertension and a condition classified to N18.- are both present. An additional N18.- code is required to identify the CKD stage. In this case, the documented stage is 3b.
A provider query solely to establish the hypertension-CKD relationship is unnecessary because ICD-10-CM itself supplies the presumed relationship. However, a query could become necessary if the physician explicitly states or strongly suggests that the CKD is unrelated to hypertension or if conflicting documentation exists.
The CDI specialist must distinguish coding conventions that automatically establish certain relationships from situations in which provider linkage is mandatory. This prevents unnecessary queries and supports accurate working-DRG assignment.
CCDS Reference Topics: Hypertensive CKD; presumed causal relationships; CKD staging; coding conventions; working MS-DRG.
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NEW QUESTION # 46
A patient with dysphagia after a recent stroke develops fever, hypoxia, and a right lower-lobe infiltrate. The physician documents "pneumonia." Speech therapy documents repeated aspiration with oral intake. What is the MOST appropriate CDI action?
Answer: B
Explanation:
The record presents a legitimate opportunity to clarify the type or etiology of pneumonia, particularly whether aspiration contributed to the pulmonary infection. Dysphagia following stroke, documented aspiration during oral intake, fever, hypoxia, and a dependent-lobe infiltrate form a clinically relevant pattern.
However, the CDI specialist cannot independently convert unspecified pneumonia into aspiration pneumonia.
Likewise, the speech-language pathologist can provide valuable clinical evidence regarding swallowing dysfunction and aspiration risk, but that documentation does not independently establish the medical diagnosis of aspiration pneumonia for coding purposes.
A compliant query should objectively present the pertinent indicators and allow the provider to identify aspiration pneumonia, another pneumonia type, pneumonitis, another condition, or inability to determine.
Automatically assigning both bacterial and aspiration pneumonia would also be inappropriate because neither bacterial etiology nor a separate second pneumonia diagnosis has been established.
The current ACDIS/AHIMA guidance emphasizes that queries should arise from the clinical record and preserve the provider's independent judgment rather than directing a preferred diagnosis.
CCDS Reference Topics: Pneumonia specificity; aspiration; dysphagia; interdisciplinary documentation; compliant query development.
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NEW QUESTION # 47
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: C
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 # 48
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