CCDS Exam — Questions and Answers

Question 1: When coding a patient who develops ventilator-associated pneumonia (VAP) during an ICU stay, which ICD-10-CM code is assigned?

J18.9 - Pneumonia, unspecified organism
J22 - Unspecified acute lower respiratory infection
J95.851 - Ventilator-associated pneumonia (Correct answer)
J15.9 - Unspecified bacterial pneumonia

Correct answer: J95.851 - Ventilator-associated pneumonia

J95.851 is the specific ICD-10-CM code for ventilator-associated pneumonia. It is a complication of care code and should only be assigned when the physician has documented VAP.

Question 2: A physician consistently documents 'urosepsis' without specifying if the patient has sepsis. What is the best long-term educational strategy for the CDS?

Ask the coding department to always code 'urosepsis' to the UTI code.
Report the physician to the Chief Medical Officer for non-compliant documentation.
Continue to send a query on every case until the physician changes their behavior.
Provide the physician with a brief educational tip sheet explaining the clinical and coding definitions of sepsis and how 'urosepsis' is ambiguous. (Correct answer)

Correct answer: Provide the physician with a brief educational tip sheet explaining the clinical and coding definitions of sepsis and how 'urosepsis' is ambiguous.

Providing a brief, evidence-based educational tip sheet or a face-to-face conversation explains the 'why' behind the need for specific documentation. It addresses the root cause of the documentation issue in a collaborative way, rather than just repeatedly querying the same issue.

Question 3: A physician documents 'acute respiratory failure due to COPD exacerbation.' Which sequencing approach is correct for an inpatient admission?

Always sequence acute respiratory failure as principal diagnosis
Always sequence COPD exacerbation as principal diagnosis
Sequence the condition requiring the most resources first
Either condition may be sequenced first per coding guidelines (Correct answer)

Correct answer: Either condition may be sequenced first per coding guidelines

ICD-10-CM guidelines allow either acute respiratory failure or the underlying condition to be sequenced as the principal diagnosis when both are present at admission.

Question 4: HIPAA is relevant to CDI practice primarily in that it:

Prohibits CDI specialists from sending queries to physicians in paper form
Protects patient health information accessed during chart review and limits its use to permitted purposes such as treatment, payment, and healthcare operations (Correct answer)
Mandates that electronic health records be used at all hospitals with CDI programs
Sets minimum documentation standards for physician queries under the Privacy Rule

Correct answer: Protects patient health information accessed during chart review and limits its use to permitted purposes such as treatment, payment, and healthcare operations

HIPAA's Privacy and Security Rules govern how protected health information (PHI) is accessed, used, and disclosed. CDI chart reviews involve access to PHI, and CDI specialists must ensure that information is used only for permitted purposes (e.g., improving documentation for coding and billing) and is not disclosed improperly.

Question 5: The Uniform Hospital Discharge Data Set (UHDDS) provides official definitions for which of the following?

Sepsis-3 clinical criteria
Principal diagnosis and other diagnoses (Correct answer)
Appropriate use of physician queries
Hospital-Acquired Conditions (HACs)

Correct answer: Principal diagnosis and other diagnoses

The UHDDS was established to create a standardized system for collecting hospital data. It provides the core definitions for principal diagnosis, other (secondary) diagnoses, and significant procedures, which are foundational to inpatient coding and reporting.

Question 6: A CDI specialist is educating a new team member about the difference between a 'present on admission' (POA) indicator of 'Y' versus 'W.' Which statement is CORRECT?

'W' means the condition was a hospital-acquired complication; 'Y' means it was not
'Y' means the condition was present at admission; 'W' means clinically undetermined at time of admission (Correct answer)
Both indicators have the same impact on quality reporting
'Y' means the condition was not present at admission; 'W' means it was present

Correct answer: 'Y' means the condition was present at admission; 'W' means clinically undetermined at time of admission

'Y' (yes) means the condition was present on admission, while 'W' (clinically undetermined) is used when it cannot be determined based on available documentation.

Question 7: What is the primary reason the designation of a procedure as 'OR' versus 'Non-OR' is critical for a CDS to recognize?

It is the primary determinant for assigning a case to a surgical MS-DRG. (Correct answer)
It determines the length of the post-operative recovery period.
Non-OR procedures are never coded on the claim.
It is only used for internal hospital quality tracking.

Correct answer: It is the primary determinant for assigning a case to a surgical MS-DRG.

The assignment of a principal procedure that is on the ICD-10-PCS OR procedure list is a fundamental driver of the MS-DRG logic. It is the main switch that moves an inpatient case from a medical DRG to a surgical DRG, which typically results in higher reimbursement.

Question 8: A CDI specialist wants to query about encephalopathy but the physician's notes only mention 'confusion.' Which approach is MOST compliant?

Send a query citing lab values, nursing notes, and imaging that support altered brain function (Correct answer)
Do not query since 'confusion' is an acceptable alternative to encephalopathy
Send a query stating 'Please document encephalopathy to support the MCC code'
Change the documentation from 'confusion' to 'encephalopathy' without a query

Correct answer: Send a query citing lab values, nursing notes, and imaging that support altered brain function

The compliant approach is to send a query citing the specific clinical indicators in the record such as abnormal labs, imaging findings, or nursing assessments that support a diagnosis of encephalopathy. The query should offer encephalopathy as one of multiple clinically plausible options.

Question 9: What is the CDI specialist's role in skin substitute graft documentation for wound care procedures?

Defer entirely to the surgical department for all graft-related documentation
Review only the patient's insurance coverage for graft approval
Verify only that informed consent was signed before the procedure
Verify documentation of the specific graft product and wound site to support accurate ICD-10-PCS procedure coding (Correct answer)

Correct answer: Verify documentation of the specific graft product and wound site to support accurate ICD-10-PCS procedure coding

Skin substitute graft procedure codes in ICD-10-PCS vary by the specific product used and the anatomic site of application, requiring CDI to verify both elements are documented.

Question 10: A physician documents 'the patient's wound is healing well' without specifying wound type or stage. What is the CDS's best action?

Assign a non-specific wound code and close the record
Accept the documentation as clinically sufficient
Escalate directly to the compliance department
Query the physician to clarify wound type, etiology, and current stage (Correct answer)

Correct answer: Query the physician to clarify wound type, etiology, and current stage

Vague wound documentation lacks the specificity needed for accurate ICD-10-CM coding, requiring a physician query to capture the correct diagnosis.

Question 11: A patient is admitted for coronary artery disease and undergoes cardiac catheterization. The catheterization reveals triple-vessel disease, and the patient proceeds to CABG during the same admission. Which procedure is the principal procedure?

Cardiac catheterization, as it established the diagnosis leading to CABG
CABG, as it is the definitive therapeutic procedure for the principal diagnosis (Correct answer)
Cardiac catheterization, as it was performed first
Both procedures share equal principal procedure status

Correct answer: CABG, as it is the definitive therapeutic procedure for the principal diagnosis

CABG is the definitive therapeutic procedure for coronary artery disease. The cardiac catheterization was a diagnostic procedure that preceded the treatment. Under UHDDS guidelines, the therapeutic procedure is the principal procedure.

Question 12: A patient with Type 2 diabetes is admitted for a diabetic foot ulcer. The record documents the ulcer extends to bone. Which ICD-10-CM code best captures the depth?

L97.504 - Non-pressure chronic ulcer of other part of foot with necrosis of bone (Correct answer)
L97.503 - Non-pressure chronic ulcer of other part of foot with necrosis of muscle
L97.509 - Non-pressure chronic ulcer of other part of foot, unspecified severity
E11.621 - Type 2 diabetes mellitus with foot ulcer

Correct answer: L97.504 - Non-pressure chronic ulcer of other part of foot with necrosis of bone

When an ulcer extends to bone, ICD-10-CM provides a specific code indicating necrosis of bone. This level of specificity is important for capturing the full severity of the condition.

Question 13: A patient is treated for both community-acquired pneumonia and COPD exacerbation during the same admission. How should this be documented?

Only the pneumonia should be documented as it is more acute
Both conditions should be documented with the one most responsible for the admission as principal (Correct answer)
COPD exacerbation should always be the principal diagnosis when present
The physician should combine them into a single diagnosis

Correct answer: Both conditions should be documented with the one most responsible for the admission as principal

Both conditions may be coded; the one established after study as chiefly responsible for the admission is sequenced as principal per UHDDS guidelines.

Question 14: Which CMS enforcement mechanism involves withholding Medicare payment for claims with specific diagnosis codes to investigate compliance with coding guidelines?

Hospital-Acquired Condition payment adjustment
Pre-Payment Review by Medicare Administrative Contractors (MACs) (Correct answer)
Recovery Audit Contractors (RACs)
Comprehensive Error Rate Testing (CERT)

Correct answer: Pre-Payment Review by Medicare Administrative Contractors (MACs)

MACs can place specific codes or DRGs under pre-payment review, withholding payment while the claim is reviewed for medical necessity and documentation compliance before reimbursement is issued.

Question 15: Which action by a CDI specialist most likely constitutes 'query harassment' under professional guidelines?

Sending repeated queries to the same physician on the same encounter after receiving a 'clinically undetermined' response (Correct answer)
Sending a query that covers two related conditions on the same form
Querying a physician about a diagnosis that appears in only one progress note
Using a query template that was not approved by the facility's compliance committee

Correct answer: Sending repeated queries to the same physician on the same encounter after receiving a 'clinically undetermined' response

Requerying a physician on the same issue after receiving a valid 'clinically undetermined' response is considered query harassment and is non-compliant.

Question 16: A patient loses 5% of body weight in 1 month due to inadequate oral intake post-surgery. Per ASPEN criteria, this weight loss severity is classified as:

Severe malnutrition
Moderate malnutrition (Correct answer)
Risk for malnutrition only, not actual malnutrition
Mild malnutrition

Correct answer: Moderate malnutrition

ASPEN criteria classify 5% weight loss in 1 month as moderate malnutrition when occurring in the context of acute illness or injury.

Question 17: A CDIS queries the physician about a central line-associated bloodstream infection (CLABSI) that developed on hospital day 5. The physician responds that it is 'likely hospital-acquired.' Which POA indicator is appropriate?

N (Correct answer)
W
Y
U

Correct answer: N

When a physician confirms the condition is hospital-acquired (arose after admission), POA indicator 'N' is appropriate, and it qualifies as a HAC.

Question 18: A CDS has sent two compliant, well-supported queries to a physician regarding the etiology of a patient's anemia, but has received no response. What is the most appropriate next step according to standard CDI practice?

Follow the department's escalation policy, which may involve notifying the CDI manager or physician advisor. (Correct answer)
Close the query as 'no response' and move on to the next chart.
Confront the physician in the hallway and demand an answer.
Add a note in the chart stating 'Physician refused to clarify anemia etiology'.

Correct answer: Follow the department's escalation policy, which may involve notifying the CDI manager or physician advisor.

A formal escalation process ensures that important documentation gaps are addressed while maintaining a professional and standardized approach. This usually involves a physician advisor who can engage the non-responsive physician in a peer-to-peer conversation.

Question 19: Under ICD-10-PCS, which root operation describes surgically cutting a body part without draining fluids or removing tissue?

Release
Division (Correct answer)
Excision
Drainage

Correct answer: Division

Division is the ICD-10-PCS root operation for cutting into or separating a body part. No tissue is removed and no fluid is drained.

Question 20: A patient is admitted for pneumonia and also undergoes a screening colonoscopy during the stay, which was scheduled prior to admission. Which statement is correct regarding principal procedure selection?

The colonoscopy is the principal procedure because it is an invasive procedure.
The chest X-ray for pneumonia is the principal procedure.
There is no principal procedure as it was unrelated to the admission's principal diagnosis. (Correct answer)
The most expensive procedure performed is always the principal procedure.

Correct answer: There is no principal procedure as it was unrelated to the admission's principal diagnosis.

The colonoscopy is unrelated to the reason for admission (pneumonia). Therefore, there is no principal procedure for this encounter, and the case will be assigned a medical MS-DRG based on the pneumonia diagnosis.

Question 21: According to the UHDDS definition, the principal procedure is one that is performed for:

The most resource-intensive purpose, regardless of intent.
Prophylactic purposes to prevent a future condition.
Definitive treatment of a condition. (Correct answer)
Diagnostic purposes to find the underlying problem.

Correct answer: Definitive treatment of a condition.

The principal procedure is performed for definitive treatment of the principal diagnosis, rather than for diagnostic or exploratory purposes. A diagnostic procedure is only selected as principal if no therapeutic procedure was performed.

Question 22: According to KDIGO criteria, Stage 1 AKI is defined as an increase in serum creatinine of at least how much within 48 hours?

0.3 mg/dL (Correct answer)
0.5 mg/dL
1.0 mg/dL
0.1 mg/dL

Correct answer: 0.3 mg/dL

KDIGO defines Stage 1 AKI as a serum creatinine increase of ≥0.3 mg/dL within 48 hours or ≥1.5 times the patient's baseline within 7 days.

Question 23: Which of the following best describes the role of the CDI specialist when reviewing MDS documentation for pressure ulcers in a skilled nursing facility (SNF) context?

Rely solely on wound care consult notes for staging accuracy
Ensure MDS Section M accurately reflects current pressure ulcer stage for PDPM case-mix grouping (Correct answer)
Focus only on ICD-10 codes in the discharge summary
Override nursing assessments with physician documentation

Correct answer: Ensure MDS Section M accurately reflects current pressure ulcer stage for PDPM case-mix grouping

In SNF settings, accurate MDS Section M pressure ulcer staging is critical because it directly impacts PDPM reimbursement through nursing case-mix classification.

Question 24: A patient undergoes a right total knee arthroplasty. The ICD-10-PCS root operation that best describes replacing the knee joint with a synthetic substitute is:

Repair
Replacement (Correct answer)
Resection
Reposition

Correct answer: Replacement

ICD-10-PCS defines 'Replacement' as putting in or on biological or synthetic material that physically takes the place of a body part.

Question 25: A patient undergoes a total knee replacement and develops a deep vein thrombosis (DVT) on post-op day 3. Which documentation could potentially exclude this case from the PSI 12 (Perioperative Pulmonary Embolism or Deep Vein Thrombosis Rate) measure?

Documentation that the patient received appropriate DVT prophylaxis.
Documentation that the surgery was elective.
Documentation that the patient ambulated on post-op day 1.
Documentation of a history of DVT within the 30 days prior to admission. (Correct answer)

Correct answer: Documentation of a history of DVT within the 30 days prior to admission.

PSI 12 has specific exclusions. If a patient had a DVT within 30 days prior to admission, the post-operative DVT is not considered a new complication for the purposes of this quality measure. Clarifying this history is a key CDI role.

Question 26: A Recovery Audit Contractor (RAC) denies payment for a sepsis claim. What is the FIRST step in the appeals process?

Recode the claim to a less complex DRG and resubmit
Submit a Redetermination request to the Medicare Administrative Contractor (MAC) within the allowed timeframe (Correct answer)
Self-disclose the underpayment to CMS immediately
Request a Qualified Independent Contractor (QIC) review as the initial step

Correct answer: Submit a Redetermination request to the Medicare Administrative Contractor (MAC) within the allowed timeframe

The Medicare appeals process begins with a Redetermination request submitted to the MAC within 120 days of the initial determination. This is the first level of appeal.

Question 27: Under ICD-10-PCS, which of the seven characters defines the specific approach used for a procedure?

Character 4 (Body Part)
Character 6 (Device)
Character 3 (Root Operation)
Character 5 (Approach) (Correct answer)

Correct answer: Character 5 (Approach)

In ICD-10-PCS, Character 5 specifies the approach used to reach the operative site, such as open, percutaneous, endoscopic, or via natural or artificial opening.

Question 28: Which ICD-10-PCS device character is used when a synthetic substitute mesh is placed during a ventral hernia repair?

Nonautologous tissue substitute (K)
Autologous tissue substitute (7)
No device (Z)
Synthetic substitute (J) (Correct answer)

Correct answer: Synthetic substitute (J)

Synthetic substitute (character J) is used in ICD-10-PCS when a synthetic mesh or other man-made material is placed during repair.

Question 29: Which situation would be MOST appropriate for a concurrent CDI review strategy rather than retrospective review?

Reviewing claims after payer adjudication for denial management
Querying physicians while the patient is still admitted to capture real-time documentation (Correct answer)
Reviewing records after final coding to identify missed diagnoses
Auditing discharged patient records for compliance purposes

Correct answer: Querying physicians while the patient is still admitted to capture real-time documentation

Concurrent review allows CDI specialists to query physicians during the active hospital stay, improving documentation before discharge and coding.

Question 30: A CDI specialist reviews a case where sepsis is documented but no organ dysfunction is noted. How does this documentation gap affect quality metrics?

It may result in undercoding severity, underestimating expected mortality (Correct answer)
It inflates the Case Mix Index artificially
It increases the hospital's PSI score favorably
It has no effect on risk-adjusted quality measures

Correct answer: It may result in undercoding severity, underestimating expected mortality

Without documentation of organ dysfunction, the case may be coded as less severe sepsis, lowering the expected mortality and potentially making actual outcomes appear worse than expected.

Question 31: Which clinical scenario most accurately represents kwashiorkor-type malnutrition (ICD-10-CM E40)?

Moderate weight loss due to inadequate carbohydrate intake
Severe protein deficiency with edema and relatively preserved body weight (Correct answer)
Mild micronutrient deficiency with normal protein levels
Severe caloric restriction with profound muscle wasting and no edema

Correct answer: Severe protein deficiency with edema and relatively preserved body weight

Kwashiorkor (E40) is characterized by severe protein deficiency with edema (protein-losing state), distinguishing it from marasmus which involves caloric wasting without edema.

Question 32: A CDS reviews a record where the physician has documented 'possible sepsis.' Under ICD-10-CM inpatient coding guidelines, how should this be coded?

Code sepsis as if it were confirmed, per inpatient uncertain diagnosis guidelines (Correct answer)
Query the physician to confirm or rule out sepsis before coding
Code the signs and symptoms of sepsis only, as the diagnosis is not confirmed
Assign a code for 'suspected infection' instead

Correct answer: Code sepsis as if it were confirmed, per inpatient uncertain diagnosis guidelines

ICD-10-CM inpatient guidelines allow coding of uncertain diagnoses such as 'possible,' 'probable,' or 'suspected' as if confirmed at the time of discharge.

Question 33: Under the Cooperating Parties coding guidelines, which organization provides the official publication for ICD-10-CM/PCS coding advice?

ACDIS (Association of Clinical Documentation Integrity Specialists)
CMS Medicare Claims Processing Manual
AHIMA Standards of Ethical Coding
AHA Coding Clinic for ICD-10-CM/PCS (Correct answer)

Correct answer: AHA Coding Clinic for ICD-10-CM/PCS

AHA Coding Clinic for ICD-10-CM/PCS is the official publication for coding guidance, published by the American Hospital Association under the authority of the Cooperating Parties (CMS, NCHS, AHA, AHIMA).

Question 34: When is a verbal physician query considered acceptable under CDI compliance standards?

For routine coding clarifications that do not affect DRG assignment
For all queries, as verbal communication is faster and more efficient
Never; all queries must be in written or electronic format
Only when the written query response is also documented in the medical record (Correct answer)

Correct answer: Only when the written query response is also documented in the medical record

Verbal queries may be used but are only acceptable if the physician's response and the clinical basis for the query are documented in the medical record.

Question 35: A patient is admitted for acute pancreatitis and subsequently requires a Whipple procedure for a newly discovered pancreatic mass. How should the principal diagnosis and principal procedure be assigned?

Principal diagnosis: pancreatitis; principal procedure: none (diagnostic only)
Principal diagnosis: pancreatic mass; principal procedure: biopsy only
Principal diagnosis: pancreatitis; principal procedure: Whipple procedure (Correct answer)
Principal diagnosis: pancreatic mass; principal procedure: Whipple procedure

Correct answer: Principal diagnosis: pancreatitis; principal procedure: Whipple procedure

The principal diagnosis remains acute pancreatitis, the condition established after study to be chiefly responsible for the admission. The Whipple procedure is the principal procedure as the definitive therapeutic surgical procedure performed during the stay.

Question 36: Under the Outpatient Code Editor (OCE), which edit would cause a claim to be returned to a provider for correction?

Reporting more than five diagnosis codes on a single claim
A procedure code that maps to a high-weighted APC
Use of a valid ICD-10-CM code that has no CPT pairing requirement
A diagnosis code not acceptable as a first-listed code on an outpatient claim (Correct answer)

Correct answer: A diagnosis code not acceptable as a first-listed code on an outpatient claim

The OCE flags diagnosis codes designated as 'unacceptable principal diagnosis' (e.g., manifestation codes), triggering a return-to-provider edit.

Question 37: When a physician responds to a query by selecting 'other — specify' and writes in a diagnosis, the CDI specialist should NEXT:

Code the written-in diagnosis immediately because the physician's response is always definitive
Return a second query asking the physician to choose one of the pre-listed options instead
Escalate to the compliance department because write-in responses are inherently non-compliant
Verify the written-in diagnosis is supported by the clinical documentation before coding it (Correct answer)

Correct answer: Verify the written-in diagnosis is supported by the clinical documentation before coding it

CDI specialists must confirm that any physician-specified diagnosis is clinically supported in the record before it is used for coding.

Question 38: According to AHIMA/ACDIS query practice guidelines, which of the following query formats is MOST compliant?

A yes/no query asking 'Does this patient have sepsis?'
A multiple-choice query offering clinically appropriate diagnoses plus 'other' and 'clinically undetermined' (Correct answer)
A verbal query with no documentation in the medical record
A query that states 'Please document sepsis to support the ICD-10 code'

Correct answer: A multiple-choice query offering clinically appropriate diagnoses plus 'other' and 'clinically undetermined'

AHIMA/ACDIS guidelines require non-leading queries that offer balanced clinical options. Multiple-choice formats listing plausible diagnoses plus 'other' and 'clinically undetermined' meet this standard.

Question 39: HCC risk adjustment is primarily used in which payment model?

Medicare Advantage and CMS-HCC capitation models (Correct answer)
Medicare Fee-for-Service inpatient reimbursement via MS-DRGs
APR-DRG severity subclass reimbursement
Medicaid CHIP programs for pediatric populations

Correct answer: Medicare Advantage and CMS-HCC capitation models

The CMS-HCC model adjusts capitation payments for Medicare Advantage plans based on the predicted health costs of each enrollee. MS-DRGs govern Medicare FFS inpatient payments and are a separate system; APR-DRGs are used by Medicaid and commercial payers.

Question 40: Under HIPAA, which role has the authority to release a patient's medical records to a CDI specialist for documentation review?

The hospital compliance officer upon receipt of a formal written request
Only the patient's attending physician after written patient authorization
Any hospital employee who requests access for quality improvement
The CDI specialist has inherent access as a member of the healthcare operations team (Correct answer)

Correct answer: The CDI specialist has inherent access as a member of the healthcare operations team

HIPAA permits covered entities to use patient health information for treatment, payment, and healthcare operations without patient authorization. CDI activities fall under healthcare operations.

Question 41: When documenting AKI secondary to rhabdomyolysis, which documentation elements are most critical for the CDS to ensure are present?

The CPK level and urine myoglobin results only
The underlying cause of the rhabdomyolysis only
Both rhabdomyolysis (M62.82) and AKI (N17.0) with a causal link documented by the physician (Correct answer)
Only the AKI code is needed; rhabdomyolysis is assumed

Correct answer: Both rhabdomyolysis (M62.82) and AKI (N17.0) with a causal link documented by the physician

Accurate coding requires the physician to document both conditions and their causal relationship; rhabdomyolysis-induced AKI most commonly maps to N17.0 (tubular necrosis) because myoglobin causes direct tubular damage.

Question 42: Which data visualization method is most effective for showing the trend of a hospital's CMI over 12 consecutive months?

Run chart (Correct answer)
Histogram
Scatter plot
Pie chart

Correct answer: Run chart

A run chart displays a single metric over time, making it ideal for tracking CMI trends across months.

Question 43: A CDI director is pressured by hospital administration to query physicians only when likely to result in a higher-weighted MS-DRG, regardless of whether clinical indicators support the query. This practice most directly violates:

The Emergency Medical Treatment and Labor Act (EMTALA)
The Joint Commission's documentation improvement standards
The Stark Law prohibiting physician self-referral
The False Claims Act and the ACDIS/AHIMA Guidelines for Achieving a Compliant Query Practice (Correct answer)

Correct answer: The False Claims Act and the ACDIS/AHIMA Guidelines for Achieving a Compliant Query Practice

Sending queries designed to drive a particular documentation outcome — rather than to clarify genuine clinical ambiguity — is a hallmark of a non-compliant query program. It can lead to unsupported diagnoses on claims, constituting false claims under the FCA. The ACDIS/AHIMA Practice Brief explicitly prohibits leading or biased queries intended to influence reimbursement.

Question 44: A provider documents 'the patient required intubation due to inability to protect the airway.' From a CDI perspective, what query is most appropriate?

Query to confirm mechanical ventilation duration
No query is needed; airway protection intubation is a procedure, not a diagnosis
Query for the specific underlying neurological or medical etiology causing airway compromise (Correct answer)
Query to add a respiratory failure code regardless of etiology

Correct answer: Query for the specific underlying neurological or medical etiology causing airway compromise

'Inability to protect the airway' is a clinical finding, not a diagnosis; the CCDS should query for the underlying cause (e.g., altered mental status, stroke, drug overdose) to support complete diagnostic coding.

Question 45: A physician responds to a query by writing 'per CDI' next to a newly added diagnosis. The CDI specialist should:

Route the chart to compliance for automatic review since the physician responded
Ask the physician to re-document using their own clinical judgment without referencing the CDI query (Correct answer)
Code the diagnosis as documented because any physician attestation is sufficient
Accept the response because the physician did sign the entry, making it legally valid

Correct answer: Ask the physician to re-document using their own clinical judgment without referencing the CDI query

Physician responses must reflect their own independent clinical judgment; 'per CDI' suggests the documentation may not meet compliance standards.

Question 46: APR-DRGs differ most fundamentally from MS-DRGs in that APR-DRGs:

Apply only to pediatric and neonatal patient populations
Do not account for secondary diagnoses when grouping cases
Are administered exclusively by CMS for Medicare Fee-for-Service inpatients
Assign independent Severity of Illness (SOI) and Risk of Mortality (ROM) subclasses in addition to the base DRG (Correct answer)

Correct answer: Assign independent Severity of Illness (SOI) and Risk of Mortality (ROM) subclasses in addition to the base DRG

APR-DRGs (All Patient Refined DRGs), developed by 3M, layer two additional dimensions — Severity of Illness and Risk of Mortality — each rated on a 1–4 scale. This provides more granular clinical complexity measurement than MS-DRGs, which only differentiate by MCC/CC/no CC.

Question 47: A CDI specialist wants to query about the specificity of a patient's anemia. Which query format is MOST compliant with AHIMA/ACDIS guidelines?

A yes/no query asking if the patient has iron deficiency anemia
A leading statement suggesting 'iron deficiency anemia appears most consistent with labs'
A multiple-choice query listing anemia types with a blank for 'other' and 'clinically undetermined' (Correct answer)
A verbal question asking the physician to pick the correct anemia type from a list read aloud

Correct answer: A multiple-choice query listing anemia types with a blank for 'other' and 'clinically undetermined'

A multiple-choice format with 'clinically undetermined' as an option is the compliant standard per AHIMA/ACDIS query guidelines.

Question 48: When querying about the type of heart failure, which response option MUST always be included in a compliant multiple-choice query?

Acute-on-chronic systolic heart failure
Normal cardiac function
Clinically undetermined (Correct answer)
Congestive heart failure, unspecified

Correct answer: Clinically undetermined

Every compliant multiple-choice query must include 'clinically undetermined' to allow the physician to indicate that the condition cannot be specified.

Question 49: When auditing coded data for PSI (Patient Safety Indicator) accuracy, a CDS specialist should focus most on the distinction between:

Principal and secondary diagnoses
ICD-10-CM and ICD-10-PCS codes
Present-on-admission (POA) and hospital-acquired conditions (Correct answer)
Inpatient and outpatient records

Correct answer: Present-on-admission (POA) and hospital-acquired conditions

PSI calculations rely heavily on POA status to determine whether a condition was pre-existing or developed during the hospitalization.

Question 50: What characterizes a deep tissue pressure injury (DTPI) and how does it differ from a staged pressure ulcer?

It is a surgical wound that becomes infected postoperatively
It describes any wound with necrotic tissue requiring debridement
It presents as persistent discoloration of intact or non-intact skin from pressure, with its own distinct ICD-10-CM code (Correct answer)
It is equivalent to a Stage 4 ulcer with visible bone exposure

Correct answer: It presents as persistent discoloration of intact or non-intact skin from pressure, with its own distinct ICD-10-CM code

DTPI presents as persistent non-blanchable discoloration (deep red, maroon, or purple) of intact or non-intact skin and has a dedicated ICD-10-CM code separate from Stage 1–4 pressure ulcers.

Question 51: A hospital's compliance audit finds that nearly all CDI queries result in documentation changes that increase DRG weight. What concern does this raise?

The CDI program is performing at peak efficiency
The coding staff needs additional training on DRG assignment
The hospital's payer mix likely skews toward more complex patients
The query process may be leading or financially motivated, warranting a compliance review (Correct answer)

Correct answer: The query process may be leading or financially motivated, warranting a compliance review

If nearly all queries result in DRG-increasing documentation changes, it may indicate that queries are being formulated in a leading manner or are clinically unjustified.

Question 52: The term 'urosepsis' is documented in the progress notes. What is the most appropriate action for the CDS?

Query the provider to clarify the specific diagnosis (e.g., UTI, sepsis). (Correct answer)
Ignore the term as it is not a valid diagnosis.
Code for urinary tract infection, as that is the implied source.
Code for sepsis, as it is clearly documented.

Correct answer: Query the provider to clarify the specific diagnosis (e.g., UTI, sepsis).

'Urosepsis' is a nonspecific term that does not have a corresponding ICD-10-CM code. The CDS must query the provider for clarification, asking if the patient has a urinary tract infection, sepsis, or both, based on the clinical indicators present.

Question 53: When analyzing physician query agreement rates, a CDS specialist notes that one physician has a 95% agreement rate while the department average is 72%. This finding most likely indicates:

The physician should be excluded from future query data
The physician has excellent documentation skills
The department average is unreliable
Queries to this physician may be leading or overly directive (Correct answer)

Correct answer: Queries to this physician may be leading or overly directive

An unusually high agreement rate may signal that queries are written in a leading manner, prompting compliance concerns.

Question 54: Which ICD-10-PCS approach value represents an endoscopic procedure performed entirely through an orifice without incision?

3 – Percutaneous
0 – Open
7 – Via Natural or Artificial Opening
8 – Via Natural or Artificial Opening Endoscopic (Correct answer)

Correct answer: 8 – Via Natural or Artificial Opening Endoscopic

Approach value '8' in ICD-10-PCS represents procedures performed via natural or artificial opening using endoscopic visualization.

Question 55: Which of the following best describes the 'non-OR procedure affecting MS-DRG assignment' designation?

Procedures that always reduce the MS-DRG weight
Procedures not performed in an OR that nonetheless shift the MS-DRG when coded (Correct answer)
Procedures coded only when they occur in an ambulatory surgery center
Procedures performed outside the OR that are ignored by the grouper

Correct answer: Procedures not performed in an OR that nonetheless shift the MS-DRG when coded

Non-OR procedures affecting MS-DRG assignment are bedside or minor procedures not done in an OR that the grouper still uses to move a case to a different (often higher) DRG.

Question 56: When is a 'Yes/No' query format considered non-compliant?

When clarifying the acuity of a condition already documented (e.g., 'Is the heart failure acute?')
When attempting to link two documented conditions (e.g., 'Is the hyponatremia due to the patient's SIADH?')
When confirming if a condition was present on admission.
When asking the physician to establish a new diagnosis based on clinical indicators. (Correct answer)

Correct answer: When asking the physician to establish a new diagnosis based on clinical indicators.

A 'Yes/No' query is non-compliant when it is used to establish a new diagnosis that has not been previously mentioned by the provider. This format can be perceived as leading the physician. It is best used for clarifying details of an already documented condition, such as acuity or linkage.

Question 57: Which of the following changes to a case would MOST likely result in a shift from a medical MS-DRG to a surgical MS-DRG?

Documenting additional days of mechanical ventilation
Adding an MCC-level secondary diagnosis
Documenting a therapeutic surgical procedure performed during the admission (Correct answer)
Changing the principal diagnosis to a more specific code

Correct answer: Documenting a therapeutic surgical procedure performed during the admission

When a therapeutic surgical procedure is performed and coded, the MS-DRG grouper typically assigns the case to a surgical DRG, which often carries a higher relative weight than the corresponding medical DRG.

Question 58: Which of the following query scenarios represents an INAPPROPRIATE use of a physician query?

Querying to confirm whether a wound infection meets criteria for postoperative wound dehiscence
Querying to clarify the clinical significance of an abnormal laboratory finding
Querying to document sepsis when the only basis is a desire to capture an MCC (Correct answer)
Querying to clarify whether anemia is acute blood loss anemia versus iron deficiency anemia

Correct answer: Querying to document sepsis when the only basis is a desire to capture an MCC

Queries must be based on clinical indicators in the record, not on financial motivations. Sending a query to capture an MCC designation for sepsis without any clinical indicators supporting sepsis is non-compliant and potentially fraudulent.

Question 59: A CDI specialist reviews a record where a patient has both acute respiratory failure and COPD exacerbation. The physician documents only 'COPD exacerbation.' What is the CDI specialist's BEST action?

Assign acute respiratory failure as the principal diagnosis without physician input
Query the physician to clarify whether acute respiratory failure is also present as a separate diagnosis (Correct answer)
Code both conditions without querying since it is clinically obvious
Ignore the acute respiratory failure since COPD is already documented

Correct answer: Query the physician to clarify whether acute respiratory failure is also present as a separate diagnosis

When clinical indicators suggest an additional diagnosis like acute respiratory failure, a compliant query to the physician is required before coding it.

Question 60: The National Coverage Determinations (NCDs) issued by CMS are binding on which entities?

State Medicaid programs only
Only acute care hospitals participating in Medicare
All Medicare contractors and providers nationwide (Correct answer)
Only Medicare Advantage plans

Correct answer: All Medicare contractors and providers nationwide

NCDs apply uniformly to all Medicare contractors and providers across the country, unlike Local Coverage Determinations which are contractor-specific.

Question 61: Which clinical scenario best supports documentation of 'pre-renal AKI' for coding and clinical purposes?

Proteinuria >3.5 g/day with hypoalbuminemia
Rising creatinine with white cell casts on urinalysis
BUN/Cr ratio >20:1 with rapid creatinine normalization after IV fluid resuscitation (Correct answer)
Creatinine rise following administration of IV contrast dye

Correct answer: BUN/Cr ratio >20:1 with rapid creatinine normalization after IV fluid resuscitation

A BUN-to-creatinine ratio >20:1 combined with prompt creatinine normalization following fluid administration is the hallmark clinical picture of pre-renal AKI due to volume depletion or reduced renal perfusion.

Question 62: When a CDI specialist conducts a 'triggered review,' what typically initiates the review?

A physician's request for documentation assistance
A random selection of charts for quality auditing purposes
Clinical criteria such as specific diagnoses, procedures, or LOS thresholds (Correct answer)
A denial letter from a payer

Correct answer: Clinical criteria such as specific diagnoses, procedures, or LOS thresholds

Triggered reviews are initiated by automated or manual flags based on specific clinical criteria such as ICU stays, certain diagnoses, high-cost procedures, or LOS outliers.

Question 63: Under the Hospital-Acquired Condition Reduction Program (HACRP), what happens to hospitals in the worst-performing quartile?

They must submit corrective action plans without financial penalty
They receive a 1% reduction in Medicare inpatient payments (Correct answer)
They receive enhanced reimbursement to fund quality improvement
They are excluded from the Medicare program

Correct answer: They receive a 1% reduction in Medicare inpatient payments

Under HACRP, hospitals in the lowest-performing quartile for hospital-acquired conditions receive a 1% reduction in all Medicare inpatient payments.

Question 64: When documenting wound tunnel length in the medical record, why is this measurement clinically significant for CDI purposes?

Tunnel length is required for all pressure ulcer codes to be valid
Tunnel length determines the ICD-10-CM stage assigned to the ulcer
Tunneling may indicate a sinus tract or abscess formation, which could support coding of an additional complication such as abscess (Correct answer)
It determines the dressing reimbursement tier under Medicare Part A

Correct answer: Tunneling may indicate a sinus tract or abscess formation, which could support coding of an additional complication such as abscess

Documented tunneling may indicate an underlying sinus tract or abscess, which the CDI specialist should query the physician to confirm and potentially code as an additional complication.

Question 65: A query asks a physician: 'Based on the elevated creatinine, BUN, and oliguria, does the patient have acute kidney injury?' This is an example of a:

Compliant query because it presents clinical evidence without steering toward a specific answer (Correct answer)
Non-compliant query because it lists too many clinical indicators
Compliant query only if the patient's creatinine value is included
Non-compliant query because kidney injury queries require nephrologist co-signature

Correct answer: Compliant query because it presents clinical evidence without steering toward a specific answer

Presenting objective clinical indicators (labs, vitals, symptoms) to support the query is compliant when no specific answer is implied.

Question 66: Which of the following BEST describes the 'clinical validity' principle as it applies to compliant query formulation?

Clinical validity means the query format has been reviewed by the facility's legal counsel
A query is clinically valid when it results in an increased MS-DRG weight
A query should only be submitted when objective clinical evidence in the record supports the possibility of the condition being queried (Correct answer)
A query is valid as long as it is signed by the attending physician within 48 hours of submission

Correct answer: A query should only be submitted when objective clinical evidence in the record supports the possibility of the condition being queried

Clinical validity requires that queries be grounded in documented clinical evidence, not assumptions or financial motivations.

Question 67: A patient develops a catheter-associated urinary tract infection (CAUTI) on day 4 of admission. Which piece of documentation is most critical for determining if this is a Hospital-Acquired Condition (HAC)?

Documentation of signs/symptoms of UTI being present on admission (POA). (Correct answer)
The patient's age and gender.
The specialty of the attending physician.
The type of antibiotic used to treat the infection.

Correct answer: Documentation of signs/symptoms of UTI being present on admission (POA).

The Present on Admission (POA) indicator is crucial for all HACs. If the signs/symptoms of the UTI were present when the patient was admitted, even if the formal diagnosis was made later, it would be considered POA and not a HAC.

Question 68: A hospital uses APR-DRG Risk of Mortality (ROM) subclasses primarily for which of the following purposes?

Benchmarking observed versus expected mortality rates for quality reporting and risk adjustment (Correct answer)
Determining whether to admit a patient to the ICU
Calculating the hospital's Medicare case-mix index
Setting nurse-to-patient staffing ratios mandated by state law

Correct answer: Benchmarking observed versus expected mortality rates for quality reporting and risk adjustment

The ROM subclass predicts the likelihood that a patient will die during the hospitalization. Hospitals use it to risk-adjust mortality statistics — comparing observed deaths to the number expected given the patient population's ROM distribution — which is central to quality benchmarking and public reporting.

Question 69: A patient has documented hypertension, heart failure, and Stage 3 CKD. Which ICD-10-CM coding approach is correct?

Use only category I12 for hypertensive CKD
Use category I11 and N18.3 only, excluding the heart failure code
Use a combination code from category I13 for hypertensive heart and chronic kidney disease with heart failure (Correct answer)
Code I10, I50, and N18.3 separately for each condition

Correct answer: Use a combination code from category I13 for hypertensive heart and chronic kidney disease with heart failure

ICD-10-CM category I13 provides combination codes for coexisting hypertension, heart failure, and CKD, replacing separate codes when all three conditions are present and linked.

Question 70: A CDI specialist sends a query for hypertensive heart disease. The physician responds 'clinically undetermined.' What is the correct action?

Code hypertensive heart disease anyway based on clinical indicators in the record
Escalate to the chief medical officer to override the physician's response
Accept the response and code without hypertensive heart disease (Correct answer)
Re-query the physician with more specific clinical indicators

Correct answer: Accept the response and code without hypertensive heart disease

When a physician responds 'clinically undetermined,' the CDI specialist must accept the response and code the case without the queried diagnosis. Physician responses including negative responses must be honored.

Question 71: A CDI specialist notices a patient receiving continuous renal replacement therapy (CRRT). What documentation query is most critical if not already present?

The type of vascular access device used for CRRT
The physician's rationale for choosing CRRT over intermittent hemodialysis
Specification of AKI Stage 3, since initiation of renal replacement therapy is a defining KDIGO criterion (Correct answer)
The number of CRRT sessions completed during the admission

Correct answer: Specification of AKI Stage 3, since initiation of renal replacement therapy is a defining KDIGO criterion

Per KDIGO criteria, initiation of any renal replacement therapy — including CRRT — automatically meets Stage 3 AKI criteria regardless of creatinine or urine output levels.

Question 72: Under the False Claims Act (FCA), which of the following scenarios could create liability for a hospital's CDI program?

Systematically sending leading queries that result in diagnoses not clinically supported, then submitting claims (Correct answer)
Tracking query response rates and educating physicians on documentation specificity
Querying physicians about clinical indicators found in the medical record
Using concurrent review to identify documentation gaps before discharge

Correct answer: Systematically sending leading queries that result in diagnoses not clinically supported, then submitting claims

Systematically sending leading or unsupported queries that result in non-clinically-supported diagnoses, then submitting Medicare claims for the resulting higher DRG, can constitute knowingly submitting false or fraudulent claims under the FCA.

Question 73: According to the ACDIS/AHIMA Guidelines for Achieving a Compliant Query Practice, which of the following best describes a compliant physician query?

A query that suggests the diagnosis the hospital's CDI program needs to meet its case-mix index targets
A query presenting clinical indicators from the record and asking the physician to clarify or confirm a diagnosis in an unbiased, open-ended or multiple-choice format (Correct answer)
A verbal query documented only in the CDI specialist's personal notes, not in the medical record
A query sent only retrospectively after final coding is complete to avoid influencing care decisions

Correct answer: A query presenting clinical indicators from the record and asking the physician to clarify or confirm a diagnosis in an unbiased, open-ended or multiple-choice format

A compliant query must be based on clinical indicators present in the record, be unbiased in format (not leading the physician toward a financially favorable answer), and be clearly documented as part of the medical record. Queries sent purely for reimbursement purposes or that suggest a specific answer violate the ACDIS/AHIMA Practice Brief and raise FCA risk.

Question 74: Which of the following conditions is on the CMS list of Hospital-Acquired Conditions (HACs) that can lead to a payment reduction if not POA?

Community-acquired pneumonia
Ventilator-associated pneumonia
Acute myocardial infarction occurring post-operatively
Falls and trauma (e.g., fracture) acquired during the stay (Correct answer)

Correct answer: Falls and trauma (e.g., fracture) acquired during the stay

The CMS HAC list includes specific, preventable conditions. A fall and trauma, such as a fracture or dislocation, that occurs after admission is a listed HAC, as are Stage 3 and 4 pressure ulcers and certain surgical site infections.

Question 75: How can CDI specialists support physician education?

By limiting access to electronic health records
By providing feedback on documentation practices and offering training sessions (Correct answer)
By replacing physicians in documentation tasks
By handling all coding responsibilities

Correct answer: By providing feedback on documentation practices and offering training sessions

CDI specialists support physician education by providing direct feedback on documentation practices and offering targeted training sessions. They educate physicians on the importance of specific, complete, and accurate documentation for patient care, coding, and quality reporting. This collaborative approach helps physicians understand documentation requirements and improve their charting habits, ultimately enhancing the overall quality of clinical records.

Question 76: A patient with CKD Stage 3 (baseline creatinine 1.8 mg/dL) presents with creatinine of 3.2 mg/dL. The physician documents 'CKD Stage 3 with acute exacerbation.' What is the best CDS action?

Code only CKD Stage 3 as documented
Code acute renal failure and CKD Stage 3
Query whether AKI on CKD should be documented, as the creatinine rise exceeds 1.5x baseline (Correct answer)
Downgrade to CKD Stage 4 based on current creatinine

Correct answer: Query whether AKI on CKD should be documented, as the creatinine rise exceeds 1.5x baseline

The creatinine rise from 1.8 to 3.2 mg/dL represents a >1.5x increase meeting AKI criteria; querying for AKI on CKD ensures accurate coding and higher DRG specificity.

Question 77: Which documentation practice best protects against a pressure ulcer being incorrectly classified as hospital-acquired?

Family confirmation of pre-existing wounds documented in the social work note
A verbal patient report of prior wounds noted in the nursing assessment
A thorough admission skin assessment with physician acknowledgment of wounds identified as present on admission (Correct answer)
Wound care orders placed on the first day of admission without physician review

Correct answer: A thorough admission skin assessment with physician acknowledgment of wounds identified as present on admission

A comprehensive admission skin assessment documented and acknowledged by the physician establishes POA status for pressure injuries, protecting the hospital from HAC designation and associated penalties.

Question 78: A CDI specialist notices that a physician's query response adds a new diagnosis that contradicts an earlier note in the same record. What should the CDI specialist do?

Escalate directly to the compliance department without notifying the physician
Accept the query response and code the new diagnosis immediately
Disregard the query response and code based on the earlier note
Notify the physician of the contradiction and ask for a clarifying addendum (Correct answer)

Correct answer: Notify the physician of the contradiction and ask for a clarifying addendum

When a query response contradicts earlier documentation, the CDI specialist should bring the contradiction to the physician's attention and request a clarifying addendum that reconciles the discrepancy.

Question 79: A CDI specialist notices a physician documents 'urosepsis' in the record. Under ICD-10-CM coding guidelines, the appropriate next step is to:

Code urosepsis directly to sepsis since the terms are synonymous in ICD-10-CM
Escalate to the CMO because 'urosepsis' is a prohibited documentation term
Code to UTI and add a note that urosepsis was documented
Query the physician to clarify whether sepsis due to a urinary tract infection or UTI alone is intended (Correct answer)

Correct answer: Query the physician to clarify whether sepsis due to a urinary tract infection or UTI alone is intended

ICD-10-CM guidelines state that 'urosepsis' is not a codeable term and requires physician clarification to distinguish sepsis from UTI.

Question 80: Under AHIMA/ACDIS standards, which of the following is a valid reason to issue a post-discharge query?

To increase DRG weight after a payer requests additional documentation
To add a secondary diagnosis that was not mentioned anywhere in the medical record
To change the principal diagnosis after the claim has already been submitted
To clarify a documented condition that is clinically ambiguous and affects coding accuracy (Correct answer)

Correct answer: To clarify a documented condition that is clinically ambiguous and affects coding accuracy

Post-discharge queries are appropriate when clinical ambiguity in the existing record affects accurate coding. The query must be based on something already documented.

Question 81: Per ICD-10-CM Official Guidelines, which of the following correctly describes coding for pressure ulcers with multiple stages documented at the same site over the course of an inpatient stay?

Code only the stage present on admission
Code each stage separately with distinct codes
Code the stage present at discharge only
Code the highest stage documented during the stay (Correct answer)

Correct answer: Code the highest stage documented during the stay

When a pressure ulcer progresses during admission, ICD-10-CM guidelines direct assignment of the code for the highest stage documented during the stay.

Question 82: In a CDI data analysis, 'DRG pairs' are used to:

Match similar patients across different hospitals for benchmarking
Identify diagnosis groups where documentation of a CC or MCC would change the DRG assignment (Correct answer)
Pair CDI specialists with specific physicians for concurrent reviews
Compare medical versus surgical DRG assignments for the same condition

Correct answer: Identify diagnosis groups where documentation of a CC or MCC would change the DRG assignment

DRG pairs or triplets are groups of related DRGs where the same base diagnosis results in different DRG assignments depending on whether a CC or MCC is documented. CDI specialists use DRG pair analysis to identify high-opportunity cases.

Question 83: Which CDI strategy is MOST effective when implementing a new CDI program in a facility with low physician engagement?

Limit CDI activity to the emergency department only
Begin with a physician champion and pilot the program in a high-volume service line (Correct answer)
Focus exclusively on retrospective record review until engagement improves
Mandate query responses within 24 hours through a new hospital policy immediately

Correct answer: Begin with a physician champion and pilot the program in a high-volume service line

Engaging a physician champion and piloting in a focused area builds credibility and early wins that encourage broader physician buy-in.

Question 84: A CDI program wants to demonstrate its value to hospital administration. Which metric BEST reflects CDI impact on quality reporting?

Total physician satisfaction scores
Improvement in Present on Admission (POA) indicator accuracy and risk-adjusted mortality rates (Correct answer)
Change in case mix index (CMI) over time
Number of queries issued per month

Correct answer: Improvement in Present on Admission (POA) indicator accuracy and risk-adjusted mortality rates

Accurate POA indicators and improved risk-adjusted mortality rates reflect CDI's impact on quality measures and hospital reputation beyond financial metrics.

Question 85: Which clinical indicator would most support a CDI query for acute kidney injury in a hospitalized patient?

Serum creatinine of 0.9 mg/dL with a baseline of 0.8 mg/dL
Blood urea nitrogen of 15 mg/dL
Urine output of 600 mL over 8 hours in a 70 kg patient
Serum creatinine rise of 0.4 mg/dL above baseline within 36 hours (Correct answer)

Correct answer: Serum creatinine rise of 0.4 mg/dL above baseline within 36 hours

A creatinine increase of 0.4 mg/dL above baseline within 36 hours exceeds the KDIGO Stage 1 threshold of ≥0.3 mg/dL within 48 hours, supporting an AKI query.

Question 86: Which approach BEST reflects a comprehensive hospital malnutrition documentation improvement program?

Requiring all patients to receive serum albumin testing for malnutrition screening
Limiting malnutrition documentation to patients with BMI below 18.5
Implementing a multidisciplinary team approach with dietitians screening, CDI querying, and physicians documenting (Correct answer)
Having CDI specialists independently diagnose and document malnutrition in the chart

Correct answer: Implementing a multidisciplinary team approach with dietitians screening, CDI querying, and physicians documenting

A comprehensive malnutrition documentation program requires a multidisciplinary approach: dietitians use validated screening tools and ASPEN criteria to identify at-risk patients, CDI specialists use dietitian assessments as triggers to query physicians, and physicians document the confirmed diagnosis.

Question 87: A CDI specialist is training new staff on query language. Which of the following phrases is MOST appropriate to include in a compliant query?

'Documentation of malnutrition would more accurately reflect the care provided and improve reimbursement.'
'Based on the following clinical indicators, can you clarify or further specify the patient's condition?' (Correct answer)
'The current documentation does not support the level of care billed; please revise accordingly.'
'Please confirm the diagnosis of septic shock to support accurate MS-DRG assignment.'

Correct answer: 'Based on the following clinical indicators, can you clarify or further specify the patient's condition?'

A compliant query asks for clarification based on clinical evidence without suggesting a specific outcome or mentioning financial impact.

Question 88: Which documented condition, if present alongside AKI, would most likely result in an MS-DRG upgrade reflecting greater patient resource intensity?

Urinary retention requiring catheterization
Acute kidney injury with tubular necrosis, classified as an MCC (Correct answer)
Incidental asymptomatic hematuria
Asymptomatic urinary tract infection

Correct answer: Acute kidney injury with tubular necrosis, classified as an MCC

AKI with tubular necrosis (N17.0) is classified as an MCC, which can significantly increase the MS-DRG weight compared to conditions classified as CCs or non-CCs.

Question 89: Which ICD-10-CM/PCS coding guideline requires a CDI specialist to distinguish between a malignant neoplasm and a personal history of cancer when reviewing documentation?

Guideline on neoplasm coding and sequencing (Correct answer)
Guideline on chronic conditions
Guideline on combination codes
Guideline on signs and symptoms

Correct answer: Guideline on neoplasm coding and sequencing

ICD-10-CM neoplasm guidelines specify distinct codes for active malignancies versus personal history of cancer, which significantly impacts severity scoring and quality metrics.

Question 90: A hospital receives a Targeted Probe and Educate (TPE) review notice from its MAC. What is the primary purpose of this review process?

To educate providers on proper billing and reduce error rates before enforcement (Correct answer)
To refer providers with high error rates to the OIG for exclusion
To impose immediate financial penalties for billing errors
To conduct unannounced on-site documentation audits

Correct answer: To educate providers on proper billing and reduce error rates before enforcement

TPE is an educational process in which MACs review a sample of claims, provide feedback, and offer education to help providers correct errors before stronger action is taken.

Question 91: A patient is admitted with acute appendicitis and undergoes a laparoscopic appendectomy. A second procedure (colonoscopy for incidental polyp removal) is also performed. Which procedure should be designated as principal?

Both procedures have equal claim to principal designation
Laparoscopic appendectomy, as it directly treats the principal diagnosis (Correct answer)
The procedure performed first in the operating suite
Colonoscopy, as it is a more complex endoscopic procedure

Correct answer: Laparoscopic appendectomy, as it directly treats the principal diagnosis

The laparoscopic appendectomy directly treats acute appendicitis, the principal diagnosis. It should be designated as the principal procedure.

Question 92: Which POA indicator is assigned when documentation is insufficient to determine if the condition was present at the time of inpatient admission?

U - Documentation is insufficient to determine POA status (Correct answer)
Y - Yes, present at time of admission
N - Not present at time of admission
W - Clinically undeterminable

Correct answer: U - Documentation is insufficient to determine POA status

The 'U' indicator is assigned when the medical record documentation does not have sufficient information to determine whether the condition was present at admission.

Question 93: When a nephrologist documents 'worsening renal function' without a specific diagnosis, what is the CDI specialist's most appropriate response?

Assign code N28.9 (disorder of kidney and ureter, unspecified) without querying
Issue a compliant query to clarify whether AKI or CKD exacerbation is the clinical diagnosis (Correct answer)
Code CKD at the most recent stage documented in prior records
Ignore the documentation since 'worsening renal function' is not a codeable condition

Correct answer: Issue a compliant query to clarify whether AKI or CKD exacerbation is the clinical diagnosis

Vague descriptions like 'worsening renal function' are not codeable diagnoses; CDI specialists should issue a compliant query when clinical indicators support AKI or another specific renal condition.

Question 94: Which quality metric measures the rate of complications that could reasonably have been prevented through optimal care?

Average Length of Stay (ALOS)
Patient Safety Indicators (PSIs) (Correct answer)
Geometric Mean Length of Stay (GMLOS)
Case Mix Index (CMI)

Correct answer: Patient Safety Indicators (PSIs)

Patient Safety Indicators (PSIs) are AHRQ-developed metrics that flag potentially preventable complications and adverse events during hospitalization. CDI specialists monitor PSIs because incomplete documentation can cause avoidable PSI flags that negatively impact hospital quality scores.

Question 95: A CDS review identifies that a patient had continuous renal replacement therapy (CRRT) for 4 days but the record only documents 'electrolyte management.' What is the appropriate CDS action?

Document acute renal failure based on the CRRT use alone
Code CRRT as a procedure without querying for the clinical indication
Add a note that CRRT was performed and close the review
Query the physician to document the reason for CRRT and whether AKI or CKD Stage 5 was the indication (Correct answer)

Correct answer: Query the physician to document the reason for CRRT and whether AKI or CKD Stage 5 was the indication

CRRT is a significant procedure that requires physician documentation of the clinical indication (typically AKI Stage 3 or ESRD) to support accurate diagnosis coding and appropriate DRG assignment.

Question 96: Which statement BEST describes the relationship between Severity of Illness (SOI) and Risk of Mortality (ROM) scores in the APR-DRG system?

SOI measures resource use while ROM independently measures likelihood of death (Correct answer)
SOI and ROM scores are averaged to produce a single quality indicator
ROM is used only for surgical DRGs while SOI applies to medical DRGs
SOI and ROM are calculated identically and always produce the same score

Correct answer: SOI measures resource use while ROM independently measures likelihood of death

In the APR-DRG system, SOI and ROM are separate, independently calculated measures. SOI reflects the extent of physiologic decompensation and resource intensity, while ROM reflects the likelihood that the patient will die.

Question 97: The UHDDS requires that secondary diagnoses be reported only when they affect patient care. Which of the following should NOT be reported?

Hypertension managed with continued home medications during the hospitalization
A historical finding documented as 'history of appendectomy 10 years ago' (Correct answer)
Type 2 diabetes requiring insulin management during the stay
Chronic kidney disease affecting medication dosing decisions

Correct answer: A historical finding documented as 'history of appendectomy 10 years ago'

A 'history of appendectomy' is a past procedure with no active management implications during the current stay. Historical conditions that do not affect current patient care, treatment, or monitoring do not meet the UHDDS reporting standard.

Question 98: A hospitalist documents 'metabolic encephalopathy' in a patient with known cirrhosis and altered mental status. What should the CDS consider querying?

Whether the patient has a history of head trauma
Whether to change the diagnosis to delirium
Whether the encephalopathy is hepatic in origin given the cirrhosis (Correct answer)
Whether the patient needs a psychiatric consultation

Correct answer: Whether the encephalopathy is hepatic in origin given the cirrhosis

When a patient has cirrhosis and encephalopathy, the CDS should query whether the encephalopathy is hepatic in etiology, as hepatic encephalopathy has a higher CC/MCC impact.

Question 99: What is the relationship between a hospital's Geometric Mean Length of Stay (GMLOS) and CDI quality efforts?

GMLOS is determined solely by nursing staffing ratios
GMLOS is unrelated to CDI documentation practices
A higher GMLOS always indicates better CDI performance
Accurate CC/MCC capture through CDI can align GMLOS with appropriate DRG benchmarks (Correct answer)

Correct answer: Accurate CC/MCC capture through CDI can align GMLOS with appropriate DRG benchmarks

Capturing Complications and Comorbidities (CC) and Major Complications and Comorbidities (MCC) through CDI queries moves cases to higher-weighted DRGs with longer expected GMLOS, better reflecting the patient's acuity.

Question 100: Which of the following best explains the 'hierarchical' principle in the HCC model?

HCC codes rank diagnoses chronologically by date of first diagnosis
Physicians must document diagnoses in order of clinical priority within the encounter
Within a disease category, only the most severe condition is counted; less severe conditions in the same category are suppressed (Correct answer)
Each HCC maps to exactly one MS-DRG grouper category

Correct answer: Within a disease category, only the most severe condition is counted; less severe conditions in the same category are suppressed

The hierarchical structure ensures that a patient with metastatic cancer does not also receive an HCC credit for localized cancer of the same type — only the highest-severity condition within a disease hierarchy is counted. This prevents 'double-counting' of related conditions.

Question 101: When coding a patient with HIV disease who is admitted for an unrelated condition (e.g., a broken leg), what is the correct sequencing per ICD-10-CM guidelines?

Sequence the unrelated condition first, with B20 as an additional code
Sequence whichever condition required more resources as principal
Always sequence B20 (HIV disease) as the principal diagnosis (Correct answer)
Do not code HIV if it was not treated during the encounter

Correct answer: Always sequence B20 (HIV disease) as the principal diagnosis

ICD-10-CM guidelines instruct that B20 is always sequenced as the principal diagnosis when a patient with HIV is admitted, regardless of the reason for admission.

Question 102: A patient on vancomycin for MRSA bacteremia develops creatinine rise from 0.8 to 2.1 mg/dL. The physician documents 'drug-induced nephropathy.' What additional documentation should the CDS seek?

Whether the patient has underlying CKD
Documentation of the MRSA source only
Only the vancomycin trough levels
The specific drug name and whether it is an adverse effect or poisoning (Correct answer)

Correct answer: The specific drug name and whether it is an adverse effect or poisoning

Accurate coding requires identifying the specific causative drug and classifying the encounter as an adverse effect (drug taken correctly) versus a poisoning or underdosing, as this affects the T-code selection paired with the nephropathy code.

Question 103: The MS-DRG system groups cases into Major Diagnostic Categories (MDCs) primarily based on which factor?

The discharge disposition
The principal diagnosis (Correct answer)
The patient's age and sex
The principal procedure

Correct answer: The principal diagnosis

MDC assignment is driven by the principal diagnosis, which determines the body system or disease category for the case.

Question 104: Which compliance framework do hospitals use to structure internal CDI and coding compliance programs?

The UHDDS Data Element Reporting Requirements
The Joint Commission ORYX Performance Measurement System
The CMS Conditions of Participation for Medical Records
The OIG Seven Elements of an Effective Compliance Program (Correct answer)

Correct answer: The OIG Seven Elements of an Effective Compliance Program

The OIG's Seven Elements of an Effective Compliance Program provide the foundational structure for hospital compliance programs, including CDI and coding compliance.

Question 105: Which CDI strategy is MOST effective for improving documentation of malnutrition in hospitalized patients?

Automatically adding malnutrition to the problem list when a dietitian documents it
Reviewing dietary consultation notes and querying physicians when nutritional criteria are met (Correct answer)
Relying on BMI thresholds alone to identify malnourished patients for coding
Deferring malnutrition documentation to the discharge summary

Correct answer: Reviewing dietary consultation notes and querying physicians when nutritional criteria are met

The most effective strategy is reviewing dietitian consultation notes for documented nutritional criteria per ASPEN/AND guidelines and querying the attending physician to confirm or deny malnutrition as a diagnosis. Physician confirmation is required for coding.

Question 106: Which of the following BEST describes a 'leading' query format that violates CDI compliance standards?

A multiple-choice query listing several diagnostic options including 'other' and 'clinically undetermined'
A query that presents only the diagnosis the CDI specialist wants the physician to confirm (Correct answer)
A query that cites specific clinical indicators from the medical record
An open-ended query asking the physician to document the clinical significance of a lab finding

Correct answer: A query that presents only the diagnosis the CDI specialist wants the physician to confirm

A leading query presents only the desired diagnosis without offering alternatives, effectively directing the physician to a predetermined answer. AHIMA and ACDIS guidelines require queries to be non-leading, offering clinically appropriate options including 'other' and 'clinically undetermined.'

Question 107: A CDI specialist notices that a hospital's Patient Safety Indicator (PSI) 90 composite score has worsened. Which action would be MOST effective?

Appealing all PSI scores with CMS directly
Reviewing cases that triggered PSI flags to identify documentation gaps or true quality events (Correct answer)
Focusing exclusively on improving CMI
Increasing query volume for all admitted patients

Correct answer: Reviewing cases that triggered PSI flags to identify documentation gaps or true quality events

Analyzing cases that contributed to PSI 90 allows CDI and quality teams to determine whether scores reflect true adverse events or documentation gaps requiring clarification.

Question 108: A hospital's CDI program tracks 'documentation integrity rate,' defined as the percentage of medical records that accurately reflect the patient's clinical condition without requiring post-discharge amendments. A low rate indicates:

Concurrent CDI review is failing to catch documentation gaps before discharge (Correct answer)
Physicians are responding to queries too quickly without clinical review
The hospital has an unusually high patient acuity that exceeds CDI capacity
CDI staff are reviewing too many charts concurrently

Correct answer: Concurrent CDI review is failing to catch documentation gaps before discharge

A low documentation integrity rate means records frequently need post-discharge amendments, indicating that the concurrent CDI review process is not catching documentation gaps before the patient is discharged.

Question 109: A patient with severe heart failure has significant peripheral edema and ascites. How does this affect malnutrition assessment and documentation?

Edema is a sign of adequate protein stores and argues against malnutrition
Fluid retention increases muscle mass measurements, excluding malnutrition diagnosis
ICD-10-CM excludes malnutrition coding when significant fluid retention is present
Fluid retention overestimates body weight, potentially masking weight loss from malnutrition (Correct answer)

Correct answer: Fluid retention overestimates body weight, potentially masking weight loss from malnutrition

In patients with significant edema or ascites, body weight is overestimated because fluid accumulation masks actual lean tissue loss.

Question 110: A patient is admitted post-cardiac arrest with ROSC (return of spontaneous circulation). The physician documents 'anoxic brain injury' and 'acute respiratory failure.' What is the CDI specialist's priority query?

Accept cardiac arrest as principal and code anoxic brain injury as secondary
Code acute respiratory failure as principal since it requires the most resources
Query to confirm the cardiac arrest cause before assigning any codes
Query to clarify the principal diagnosis and whether cardiac arrest or anoxic brain injury drives the admission (Correct answer)

Correct answer: Query to clarify the principal diagnosis and whether cardiac arrest or anoxic brain injury drives the admission

Determining the principal diagnosis among post-arrest complications requires physician clarification to ensure the condition that drove the admission is correctly identified.

Question 111: Which ICD-10-PCS root operation is used when a surgeon removes a kidney stone using an endoscope introduced through the urethra?

Extraction
Fragmentation
Excision
Extirpation (Correct answer)

Correct answer: Extirpation

Extirpation is the root operation for taking or cutting out solid matter such as a calculus from a body part. For a kidney stone removed via endoscopic approach through the urethra, Extirpation with a via natural or artificial opening endoscopic approach would be coded.

Question 112: A patient is admitted after a fall from a ladder at a construction site. The injury is a closed fracture of the femoral shaft. Which ICD-10-CM code captures the external cause of the initial encounter?

X58.XXXA
W11.XXXA (Correct answer)
Y93.H9XA
W19.XXXA

Correct answer: W11.XXXA

W11.XXXA represents a fall on and from a ladder, initial encounter, which correctly captures the external cause mechanism.

Question 113: Which approach BEST supports CDI success in capturing malnutrition documentation?

Collaborating with dietitians to identify patients meeting malnutrition criteria and then querying the physician (Correct answer)
Waiting until discharge to query the physician about nutritional status
Querying only when the patient has a BMI below 18
Coding malnutrition based on low albumin levels alone without a query

Correct answer: Collaborating with dietitians to identify patients meeting malnutrition criteria and then querying the physician

Interdisciplinary collaboration with dietitians helps CDI specialists identify malnutrition criteria (per ASPEN guidelines) and support timely, evidence-based physician queries.

Question 114: A physician documents 'troponin leak post-cardioversion.' The CDI specialist reviews the record and sees no MI documented. What is the appropriate CDI action?

Code elevated troponin as the principal diagnosis
Code NSTEMI since any troponin elevation meets MI criteria
Take no action since troponin leak is a known complication of cardioversion
Query whether the troponin elevation represents myocardial injury, Type 2 MI, or a procedure-related finding (Correct answer)

Correct answer: Query whether the troponin elevation represents myocardial injury, Type 2 MI, or a procedure-related finding

Troponin elevation post-cardioversion may represent Type 2 MI or procedural myocardial injury, and physician clarification is needed for accurate code assignment.

Question 115: Which CKD stage corresponds to a GFR of 15–29 mL/min/1.73m²?

Stage 3a
Stage 3b
Stage 4 (Correct answer)
Stage 5

Correct answer: Stage 4

CKD Stage 4 is defined by a GFR of 15–29 mL/min/1.73m², representing severely decreased kidney function approaching end-stage disease.

Question 116: Which of the following is a key difference between the ICD-10-CM definition of 'severe sepsis' (R65.2x) and the Sepsis-3 clinical definition?

ICD-10-CM severe sepsis requires a SOFA score ≥4; Sepsis-3 uses ≥2
ICD-10-CM severe sepsis requires bacteremia; Sepsis-3 does not
Sepsis-3 eliminated the term 'severe sepsis'; ICD-10-CM retains it for coding purposes (Correct answer)
There is no difference; ICD-10-CM updated to mirror Sepsis-3 in 2017

Correct answer: Sepsis-3 eliminated the term 'severe sepsis'; ICD-10-CM retains it for coding purposes

Sepsis-3 eliminated 'severe sepsis' as a clinical category, but ICD-10-CM continues to use R65.20/R65.21 for coding organ dysfunction associated with sepsis.

Question 117: Which element is REQUIRED to be included in every compliant physician query?

The DRG impact of the physician's potential response
Clinical indicators from the medical record that prompted the query (Correct answer)
The specific ICD-10-CM code the CDI specialist is seeking
The identity of the insurance payer for the case

Correct answer: Clinical indicators from the medical record that prompted the query

Every compliant query must cite the specific clinical indicators from the medical record that prompted the question. This demonstrates that the query is clinically based and not financially motivated.

Question 118: Which CDI strategy is MOST effective for improving physician query response rates?

Sending queries only at discharge to avoid interrupting care
Limiting queries to high-revenue DRGs only
Escalating all unanswered queries to the compliance department immediately
Building relationships with physicians and educating them on the impact of documentation (Correct answer)

Correct answer: Building relationships with physicians and educating them on the impact of documentation

Physician education and relationship-building are proven strategies for improving query response rates and overall documentation quality.

Question 119: Under AHIMA's 2019 compliant query guidelines, which of the following must be included in every written query?

A signature line for the physician to attest to medical necessity
The CDI specialist's credentials and the anticipated reimbursement change
Physician's DEA number, patient insurance ID, and estimated MS-DRG impact
Patient name, account number or date of service, and the clinical indicators supporting the query (Correct answer)

Correct answer: Patient name, account number or date of service, and the clinical indicators supporting the query

AHIMA guidelines require patient identifiers, relevant clinical indicators, and a clear question with balanced response options.

Question 120: What is the role of a Clinical Documentation Specialist (CDS) in a CDI program?

To train healthcare providers on new technologies
To manage hospital finances
To review and improve clinical documentation and ensure it supports coding and billing (Correct answer)
To provide patient care directly

Correct answer: To review and improve clinical documentation and ensure it supports coding and billing

A Clinical Documentation Specialist (CDS) plays a crucial role in a CDI program by reviewing patient medical records concurrently or retrospectively. Their main responsibility is to identify discrepancies, inconsistencies, or missing information in the documentation and query healthcare providers for clarification. This ensures that the documentation accurately reflects the patient's severity of illness, risk of mortality, and the services provided, thereby supporting accurate coding and billing.

Question 121: Under ICD-10-CM guidelines, when a patient is admitted for chemotherapy and develops a complication during the inpatient stay, what is the correct principal diagnosis?

The complication if it required surgical intervention; otherwise the malignancy
Encounter for antineoplastic chemotherapy (Z51.11) (Correct answer)
The malignancy for which chemotherapy is being administered
The complication that developed during the stay

Correct answer: Encounter for antineoplastic chemotherapy (Z51.11)

ICD-10-CM guidelines specify that when admission is for chemotherapy, Z51.11 is sequenced as principal regardless of complications that arise during the stay.

Question 122: Which data source does CMS primarily use to calculate risk-adjusted quality measures such as mortality and readmissions for hospital comparison?

Medicare fee-for-service claims data (Correct answer)
State health department records
Hospital incident reports submitted quarterly
Voluntary hospital quality surveys

Correct answer: Medicare fee-for-service claims data

CMS uses Medicare fee-for-service claims data submitted by hospitals to calculate risk-adjusted quality measures including mortality and 30-day readmission rates for public reporting.

Question 123: When is it appropriate for a coder to assign the POA indicator 'U' (Unknown)?

When a condition develops 24 hours after admission.
When the physician documents 'possible' for a diagnosis.
When the documentation is insufficient to make a determination. (Correct answer)
When the physician explicitly writes 'POA unknown' in the chart.

Correct answer: When the documentation is insufficient to make a determination.

The 'U' indicator should be used as a last resort when the medical record documentation is insufficient to determine if the condition was present at the time of admission. This indicates a documentation gap that could not be clarified.

Question 124: Which ICD-10-CM code is assigned for end-stage renal disease (ESRD) requiring renal replacement therapy?

N18.6 (Correct answer)
N18.5
N17.9
N19

Correct answer: N18.6

N18.6 is the specific ICD-10-CM code for ESRD, which is distinct from N18.5 (CKD Stage 5) and indicates dependency on dialysis or other renal replacement therapy.

Question 125: A hospitalist documents 'possible CHF exacerbation, probable pneumonia' in the discharge summary. How should the final codes reflect this?

Code only the condition that results in the higher DRG
Code only 'pneumonia' as it is the more specific of the two diagnoses
Code neither condition since both are uncertain
Code both CHF exacerbation and pneumonia per the inpatient uncertain diagnosis guideline (Correct answer)

Correct answer: Code both CHF exacerbation and pneumonia per the inpatient uncertain diagnosis guideline

Under ICD-10-CM inpatient guidelines (Section II), conditions documented as 'possible,' 'probable,' or similar uncertain terms at the time of discharge are coded as if established. Both CHF exacerbation and pneumonia meet this standard and should be coded.

Question 126: Under ICD-10-CM Official Guidelines, the 'Excludes1' note indicates:

The excluded code may be used together with the code it is excluded from
The two conditions cannot occur simultaneously and cannot be coded together (Correct answer)
The excluded code should always be sequenced before the primary code
The condition is included in the code and should not be coded separately

Correct answer: The two conditions cannot occur simultaneously and cannot be coded together

An Excludes1 note indicates a pure exclusion. The two conditions are mutually exclusive and cannot coexist in the same patient. Therefore they cannot be coded together.

Question 127: Under ICD-10-CM coding guidelines, if a patient has a pressure ulcer that is documented at Stage 2 on admission but progresses to Stage 3 during the stay, which stage is coded?

Stage 2, the stage at admission
Both Stage 2 and Stage 3 with separate codes
Stage 3, the highest stage documented during the encounter (Correct answer)
Unstageable, since the wound changed

Correct answer: Stage 3, the highest stage documented during the encounter

Per ICD-10-CM guidelines, when a pressure ulcer progresses during an encounter, the code for the highest stage documented is assigned.

Question 128: A CDI program is evaluating its query impact. Which metric DIRECTLY measures the financial effect of CDI activities?

Query response rate
Query agreement rate
Revenue per query or DRG shift value (Correct answer)
Physician query volume per CDI specialist

Correct answer: Revenue per query or DRG shift value

Revenue per query or DRG shift value directly quantifies the financial impact of CDI activities by calculating the dollar value of DRG weight changes resulting from documentation improvements.

Question 129: Which of the following would be considered a reportable secondary diagnosis?

A condition mentioned in the ED note but not addressed again.
Chronic hypertension managed with home medications that are continued during the stay. (Correct answer)
A family history of colon cancer.
A resolved case of pneumonia from two years ago.

Correct answer: Chronic hypertension managed with home medications that are continued during the stay.

According to UHDDS, a secondary diagnosis is a condition that coexists at admission or develops subsequently, and affects patient care in terms of requiring clinical evaluation, therapeutic treatment, diagnostic procedures, extended length of stay, or increased nursing care/monitoring.

Question 130: The ICD-10-CM guideline for 'code also' notes instructs the coder to:

Assign the 'code also' code only when it affects treatment or management
Sequence the 'code also' code as the principal diagnosis
Always assign both codes in the stated order
Assign the 'code also' code only if the condition is documented as present (Correct answer)

Correct answer: Assign the 'code also' code only if the condition is documented as present

'Code also' notes indicate that a second code may be needed if the underlying condition is documented; if not documented, only the primary code is assigned.

Question 131: What is the CDI specialist's primary role when an ICD (implantable cardioverter-defibrillator) is placed during an admission?

Verify documentation of the clinical indication and device type for accurate procedure and diagnosis coding (Correct answer)
Review only the surgeon's operative note for completeness
Confirm the device is documented anywhere in the chart
No CDI review is needed for device implantation procedures

Correct answer: Verify documentation of the clinical indication and device type for accurate procedure and diagnosis coding

CDI must verify documentation of the clinical indication (e.g., LVEF ≤35%, sustained VT) and device type (single vs. dual chamber) to support accurate procedure coding and DRG assignment.

Question 132: Which of the following conditions would most likely map to a high-value HCC category, making it a priority for CDI query?

Acute sinusitis
Type 2 diabetes with diabetic chronic kidney disease, stage 3 (Correct answer)
Common cold
Hypertension without complications

Correct answer: Type 2 diabetes with diabetic chronic kidney disease, stage 3

Diabetes with CKD as a complication maps to a high-severity HCC category because it predicts significantly higher expected healthcare costs. Hypertension without complications, acute sinusitis, and viral URIs carry little or no HCC weight, as they do not substantially predict elevated resource utilization.

Question 133: A patient admitted for elective knee replacement develops a deep surgical site infection (SSI) post-operatively. Under HAC rules, how does documentation of the SSI affect reimbursement?

The SSI code is excluded from the claim entirely to avoid payment penalty
The SSI is coded with POA=Y to avoid payment reduction
The SSI is coded but POA=N triggers the HAC payment adjustment, reducing reimbursement (Correct answer)
The SSI is coded with POA=W since surgical complications are clinically undeterminable

Correct answer: The SSI is coded but POA=N triggers the HAC payment adjustment, reducing reimbursement

SSI is a CMS-designated HAC. Since it developed post-operatively (not present at admission), it is coded with POA=N. This triggers the HAC payment adjustment where CMS reassigns the DRG to the version without the SSI complication, reducing payment.

Question 134: A physician documents 'possible aspiration pneumonia' in the H&P but does not confirm or deny it was present on admission. What POA indicator should be assigned?

N
W
Y
U (Correct answer)

Correct answer: U

When documentation is insufficient to determine whether a condition was present on admission, the POA indicator 'U' (unknown) is assigned.

Question 135: A patient with end-stage renal disease is admitted with confusion and altered mental status. The physician documents only 'AMS.' Which query is most clinically appropriate for the CDI specialist to send?

Query for septic encephalopathy
No query is needed; AMS is adequately specific
Query for Wernicke's encephalopathy
Query for uremic encephalopathy (Correct answer)

Correct answer: Query for uremic encephalopathy

End-stage renal disease causes accumulation of uremic toxins that impair brain function, making uremic encephalopathy the most clinically supported and specific diagnosis. 'AMS' does not capture this etiology and will not map to an MCC, while uremic encephalopathy does.

Question 136: Which of the following is a Hospital-Acquired Condition (HAC) that directly affects Medicare payment if not documented as present on admission?

Type 2 diabetes
Catheter-associated urinary tract infection (CAUTI) (Correct answer)
Hypertension
Chronic obstructive pulmonary disease (COPD)

Correct answer: Catheter-associated urinary tract infection (CAUTI)

CAUTI is one of the CMS-designated Hospital-Acquired Conditions. If a urinary tract infection develops after admission and is not documented as present on admission, Medicare will not reimburse the additional cost of treating that complication.

Question 137: The quick SOFA (qSOFA) score includes which three clinical criteria?

Fever above 38 degrees C, WBC above 12,000/mm3, heart rate above 90 bpm
Altered mentation, respiratory rate at or above 22 per minute, systolic blood pressure at or below 100 mmHg (Correct answer)
Lactate above 2 mmol/L, systolic BP below 90, temperature below 36 degrees C
WBC below 4,000, creatinine above 2.0, bilirubin above 2.0 mg/dL

Correct answer: Altered mentation, respiratory rate at or above 22 per minute, systolic blood pressure at or below 100 mmHg

The qSOFA score uses three bedside criteria: altered mentation (GCS below 15), respiratory rate at or above 22 breaths per minute, and systolic blood pressure at or below 100 mmHg. A qSOFA score of 2 or more identifies patients at higher risk for sepsis-related organ dysfunction.

Question 138: A physician documents 'respiratory insufficiency' for a patient on 3L nasal cannula. A CDI specialist considers querying for respiratory failure. What clinical threshold is commonly referenced to distinguish insufficiency from failure?

Respiratory rate above 20 breaths per minute requiring supplemental oxygen
PaO2 below 60 mmHg or PaCO2 above 50 mmHg (acute), indicating inability to maintain adequate gas exchange (Correct answer)
SpO2 below 94% on room air regardless of supplemental oxygen
PaO2 below 80 mmHg on room air

Correct answer: PaO2 below 60 mmHg or PaCO2 above 50 mmHg (acute), indicating inability to maintain adequate gas exchange

Clinical criteria commonly referenced for acute respiratory failure include PaO2 below 60 mmHg or oxygen saturation below 90% (hypoxic failure) or PaCO2 above 50 mmHg with acidosis (hypercapnic failure).

Question 139: In data analysis for CDI, 'specificity' of a coded diagnosis most directly affects:

MS-DRG assignment and reimbursement accuracy (Correct answer)
The patient's length of stay
The number of queries issued per record
Nursing staff workload

Correct answer: MS-DRG assignment and reimbursement accuracy

Diagnosis specificity determines the ICD-10-CM code selected, which drives MS-DRG grouping and corresponding reimbursement.

Question 140: A patient is readmitted 15 days after discharge for pneumonia with a new diagnosis of acute MI. How can CDI documentation impact the classification of this readmission under the Hospital Readmissions Reduction Program (HRRP)?

By changing the principal diagnosis of the first admission to something other than pneumonia.
By querying to link the MI to the previous pneumonia admission.
By documenting the readmission as 'planned' in the physician's notes.
By ensuring documentation clearly supports that the MI is an unrelated, new problem, making it a distinct admission. (Correct answer)

Correct answer: By ensuring documentation clearly supports that the MI is an unrelated, new problem, making it a distinct admission.

HRRP penalizes hospitals for excess readmissions for certain conditions. If the readmission is for a clearly distinct and unrelated clinical problem, it may not count against the hospital's performance for the initial condition. CDI can help by ensuring the principal diagnosis for the second stay is clearly and accurately documented.

CCDS Exam

The Certified Clinical Documentation Specialist (CCDS) exam, administered by ACDIS, validates expertise in clinical documentation improvement including coding, query practices, data analytics, and regulatory compliance.

140

Questions

210 min

Time Limit

73%

To Pass

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