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| Section | Weight | Objectives |
|---|---|---|
| Healthcare facility CDI program analysis | 8.33% | - High-frequency DRGs - CC/MCC capture - Patient Safety Indicators - Case mix index (CMI) - Publicly reported data - Severity of illness and risk of mortality - PEPPER data - Basic computer and software application skills - CDI specialist productivity metrics - Provider response rates - Hospital Value-Based Purchasing measures - Physician performance measurement - CDI program forecasting - Tracking and trending physician, department, and hospital performance - Hospital-specific financial data |
| Medical record documentation | 19.17% | - Provider role and diagnosis code assignment - Documentation requiring clarification - Physician query formats - When a physician query is warranted - Compliant and noncompliant queries - Situations in which queries are not appropriate - Types of physician queries - Addressing diagnoses without clinical support - Translating clinical indicators into compliant queries - ACDIS/AHIMA Guidelines for Achieving a Compliant Query Practice - Clinical indicators - Health record elements used for diagnosis and procedure code assignment |
| Communication skills | 9.17% | - Verbal versus written physician communication - Roles and responsibilities of CDI specialists - Reconciling CDI working DRGs with final coded DRGs - Effective and non-confrontational physician communication - Roles and responsibilities of coders working with CDI departments - Physician education forms and tools - Educational presentations for healthcare departments and administration |
| Impact of reportable diagnoses on quality of care | 8.33% | - 30-day mortality measures - CDI impact on Hospital Value-Based Purchasing - Patient Safety Indicators - Hospital Inpatient Quality Reporting Program - Hospital Value-Based Purchasing - Documentation and code assignment impact on mortality index - Hospital-Acquired Condition Reduction Program - Coded data elements affecting Patient Safety Indicators - Quality data from record abstraction and claims data - Hospital Readmissions Reduction Program - Mortality reviews and observed/expected ratios - Healthcare-associated infections and complication codes |
| Anatomy and physiology, pathophysiology, pharmacology, and medical terminology | 19.17% | - Mental diseases and disorders - Infectious and parasitic diseases - Diseases and disorders of the digestive system - Medications as clinical indicators - Diseases and disorders of the hepatobiliary system - Injuries, poisonings, and toxic effects of drugs - Diseases and disorders of the musculoskeletal system - Diagnostic tests as clinical indicators - Endocrine, nutritional, and metabolic diseases and disorders - Standard medical abbreviations - Diseases and disorders of the kidney and urinary tract - HIV infections - 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 nervous system - Diseases and disorders of the skin, subcutaneous tissue, and breast - Clinical indicators and query opportunities by Major Diagnostic Category - Myeloproliferative diseases and disorders and poorly differentiated neoplasms - Pharmaceuticals and disease processes - Diseases and disorders of the blood and blood-forming organs and immunological disorders |
| Official Guidelines for Coding and Reporting | 14.17% | - Coding guidelines for principal diagnosis selection - Discharge dispositions and transfers - Present on admission indicators - Hospital-acquired conditions - Official Guidelines for Coding and Reporting updates - Principal diagnosis assignment - AHA Coding Clinic - Working DRG assignment for multiple diagnoses - Secondary diagnosis assignment |
| Professionalism, ethics, and compliance | 9.17% | - Potential DRG creep - DRG compliance initiatives - Leading queries - Medical record confidentiality - Compliance risks indicated by PEPPER - CDI department goals beyond reimbursement |
| Healthcare regulations, reimbursement, and documentation requirements related to the IPPS | 12.5% | - Medicare Severity Diagnosis Related Groups (MS-DRGs) - Inpatient admission criteria and CMS Two-Midnight Rule - Case mix index (CMI) - Major complication/comorbidity (MCC) - Principal diagnosis and medical necessity - Medicare contractors and their impact on CDI - Medical staff and clinical staff documentation responsibilities - Documentation and medical necessity of setting - IPPS and its updates and revisions - Documentation impact on IPPS reimbursement - Complication/comorbidity (CC) - Coding and billing practices vulnerable to denial |
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NEW QUESTION # 116
A patient presents to the ED following a motor vehicle crash with a lacerated spleen. The patient's BP is 80
/60, HR is 160, and the patient receives dopamine, a 2-L saline bolus, and 3 units of PRBCs. The physician documents MVA with lacerated spleen. Based on these clinical indicators, which of the following conditions would BEST reflect the accurate acuity of this patient?
Answer: D
Explanation:
The clinical presentation most strongly supports clarification of hypovolemic shock, specifically hemorrhagic shock in the context of traumatic splenic bleeding. Profound hypotension at 80/60 mmHg, extreme tachycardia at 160 beats/min, substantial crystalloid resuscitation, transfusion of three units of packed red blood cells, and vasopressor support demonstrate severe circulatory compromise.
Acute blood loss anemia may also be present and should be documented when clinically supported, but it does not fully represent the patient's hemodynamic instability. Shock describes failure of effective tissue perfusion and therefore more accurately captures the immediate physiologic severity.
SIRS due to trauma is less specific than the evident volume-loss state and would not adequately describe the hemorrhagic circulatory collapse. The record already identifies splenic laceration; "ruptured spleen" should not be substituted without provider confirmation and appropriate operative/imaging evidence.
For CDI purposes, this is a classic situation in which documentation of only the anatomical injury understates the patient's physiologic acuity. A neutral query can present the documented hypotension, tachycardia, transfusion, fluids, and vasoactive treatment and request clarification of the associated condition.
CCDS Reference Topics: Shock; trauma; hemorrhage; acute blood loss; severity-of-illness documentation.
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NEW QUESTION # 117
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 # 118
A patient is admitted with community-acquired pneumonia. On day 3, he begins to show signs of increasing respiratory distress and requires intubation. When he arrives in the ICU, the nurse inserts a urinary catheter and notes that his urine output has decreased. The physician documents respiratory failure and acute renal failure secondary to sepsis caused by pneumonia. The patient's condition would be classified as:
Answer: B
Explanation:
This patient has sepsis with documented acute organ dysfunction, specifically acute respiratory failure and acute renal failure. Under ICD-10-CM coding guidance, sepsis associated with acute organ dysfunction is classified as severe sepsis when the provider establishes the relationship between the systemic infection and the organ dysfunction.
The documentation specifically states that respiratory failure and acute renal failure are secondary to sepsis caused by pneumonia. That causal linkage is critical. FY 2026 Official Guidelines require the underlying systemic infection code, followed by a code from R65.2- for severe sepsis, plus additional codes identifying each associated acute organ dysfunction.
Septic shock is not supported because the scenario does not document circulatory failure attributable to sepsis, persistent hypotension requiring vasopressors, or a provider diagnosis of septic shock. "Septicemia" is also not equivalent terminology for coding sepsis and is not the appropriate classification here.
From a CDI perspective, the defining feature is not simply that the patient is critically ill. It is the documented relationship between sepsis and acute organ dysfunction.
CCDS Reference Topics: Sepsis; severe sepsis; acute organ dysfunction; sequencing guidelines.
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NEW QUESTION # 119
Which CMS resource contains the complete FY 2026 lists of diagnoses classified as MCCs and CCs for MS- DRG purposes?
Answer: A
Explanation:
CMS publishes the complete MCC and CC lists as part of the FY 2026 IPPS Final Rule supporting tables.
Specifically, the FY 2026 final-rule page identifies Table 6I as the Complete MCC List and Table 6J as the Complete CC List, along with additions, deletions, and the CC exclusion list.
These files are critical reference resources when assessing MS-DRG severity logic. Nevertheless, classification as an MCC or CC does not automatically mean that the diagnosis changes a particular case's MS-DRG. Principal-diagnosis exclusions, procedure logic, DRG structure, and the presence of another MCC can affect whether a diagnosis alters final assignment.
The Hospital Consumer Assessment survey relates to patient experience rather than diagnosis severity classification. The Physician Fee Schedule governs professional reimbursement and does not contain the inpatient MS-DRG MCC/CC classification system. National Coverage Determinations address Medicare coverage for particular services rather than MS-DRG severity categories.
CDI specialists should use the current CMS version applicable to the discharge date. CMS identifies MS- DRG Version 43.1 as effective April 1 through September 30, 2026.
CCDS Reference Topics: MCC; CC; CMS Definitions Manual; IPPS; MS-DRG severity.
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NEW QUESTION # 120
CMS identifies the complete logic used to assign inpatient cases to MS-DRGs in which FY 2026 resource?
Answer: C
Explanation:
The ICD-10 MS-DRG Definitions Manual contains the detailed grouper logic CMS uses for MS-DRG assignment. CMS states that the FY 2026 Definitions Manual files provide the complete documentation of ICD-10 MS-DRG grouper logic.
The manual organizes MS-DRGs by Major Diagnostic Category and includes the principal diagnoses, procedures, MCC/CC structure, exclusions, and other logic needed to understand how cases group.
As of September 2026, CMS identifies FY 2026 Version 43.1 as effective for discharges from April 1 through September 30, 2026. Version 44 begins October 1, 2026 for FY 2027.
The Physician Fee Schedule governs professional services and does not define inpatient MS-DRGs. HCAHPS concerns patient-experience measurement, while the National Correct Coding Initiative focuses primarily on coding edits designed to prevent inappropriate code combinations in other reimbursement contexts.
CDI specialists do not need to memorize every grouper pathway, but they should understand how principal diagnosis, secondary conditions, procedures, and CC/MCC classifications interact to determine the working and final MS-DRG.
CCDS Reference Topics: MS-DRG Definitions Manual; grouper logic; IPPS; current fiscal-year resources.
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NEW QUESTION # 121
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