CCDS Exam — Questions and Answers

Question 1: Which scenario represents an appropriate use of a verbal query according to AHIMA/ACDIS guidelines?

When the physician is known to ignore written queries
When the CDS prefers verbal communication over written forms
Routine clarification of a diagnosis that can wait until discharge
An urgent situation where a delayed written query would affect patient care or timely billing (Correct answer)

Correct answer: An urgent situation where a delayed written query would affect patient care or timely billing

Verbal queries are appropriate only when urgency exists and the query must be documented in the medical record with the physician's response.

Question 2: Which statement best reflects ICD-10-CM documentation requirements for valvular heart disease?

Mitral regurgitation requires the most specific documentation of all valve conditions
Valve severity documentation is optional for code assignment
Only aortic valve conditions need etiology documented
All valve conditions require documentation of the specific valve, etiology, and severity when applicable (Correct answer)

Correct answer: All valve conditions require documentation of the specific valve, etiology, and severity when applicable

All valvular conditions in ICD-10-CM require documentation of the specific valve affected, etiology (rheumatic vs. non-rheumatic), and clinical severity to assign the most accurate code.

Question 3: Which Present on Admission (POA) indicator is assigned when documentation is insufficient to determine if a condition was present at the time of inpatient admission?

W
Y
U (Correct answer)
N

Correct answer: U

POA indicator 'U' is assigned when documentation is insufficient to determine if the condition was present on admission.

Question 4: Which clinical scenario most accurately represents kwashiorkor-type malnutrition (ICD-10-CM E40)?

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

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 5: A CDI program's monthly report shows 30% of all queries are for sepsis documentation. What would raise the MOST concern during a compliance audit?

Queries offering options including 'sepsis,' 'infection without sepsis,' 'other,' and 'clinically undetermined'
Sepsis queries sent when the only clinical indicators are elevated WBC without documented infection (Correct answer)
High physician agreement rate for sepsis queries supported by documented infection and organ dysfunction
Post-discharge sepsis queries based on documented ICU care and vasopressor use

Correct answer: Sepsis queries sent when the only clinical indicators are elevated WBC without documented infection

Sending sepsis queries based solely on elevated WBC without documented infection lacks the clinical foundation required for a compliant query. Sepsis requires documentation of both suspected or confirmed infection and acute organ dysfunction.

Question 6: A patient admitted for a GI bleed undergoes an EGD (esophagogastroduodenoscopy) where a bleeding ulcer is identified and cauterized. How does the cauterization affect MS-DRG assignment?

It has no effect on the MS-DRG.
It qualifies the EGD as an OR procedure, moving the case to a surgical DRG. (Correct answer)
It confirms the medical diagnosis but does not change the DRG.
It lowers the relative weight because the problem was fixed.

Correct answer: It qualifies the EGD as an OR procedure, moving the case to a surgical DRG.

A purely diagnostic EGD is a non-OR procedure. Adding a therapeutic intervention like cautery makes it a significant OR procedure, which shifts the case from a medical MS-DRG (for GI bleed) to a higher-weighted surgical MS-DRG.

Question 7: A CDI specialist wants to query about encephalopathy but the physician's notes only mention 'confusion.' Which approach is MOST compliant?

Change the documentation from 'confusion' to 'encephalopathy' without a query
Send a query stating 'Please document encephalopathy to support the MCC code'
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

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 8: Which element of a physician's documentation would MOST clearly support coding of a complication of care in the inpatient setting?

A radiology report describing a finding consistent with a wound complication
A nurse's incident report documenting a medication administration error
An attending physician's progress note stating 'patient developed postoperative wound infection' (Correct answer)
A pharmacist's note identifying a potential drug interaction

Correct answer: An attending physician's progress note stating 'patient developed postoperative wound infection'

Only physician documentation can support coding a complication of care. An attending progress note explicitly stating the patient developed a postoperative wound infection is the documentation basis needed to code the complication.

Question 9: 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?

Code CRRT as a procedure without querying for the clinical indication
Add a note that CRRT was performed and close the review
Document acute renal failure based on the CRRT use alone
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 10: A CDI specialist notices that a hospital's Patient Safety Indicator (PSI) 90 composite score has worsened. Which action would be MOST effective?

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

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 11: A CDI team wants to prioritize which records to review first. Which approach represents BEST practice?

Review records randomly to ensure unbiased selection
Focus only on surgical cases regardless of clinical complexity
Review all records alphabetically by patient last name
Use a risk-stratified approach targeting high-complexity, high-LOS, or high-cost cases (Correct answer)

Correct answer: Use a risk-stratified approach targeting high-complexity, high-LOS, or high-cost cases

Risk stratification ensures CDI resources are directed toward cases with the greatest documentation improvement opportunities and financial or quality impact.

Question 12: A physician consistently documents 'urosepsis' without specifying if the patient has sepsis. What is the best long-term educational strategy for the CDS?

Continue to send a query on every case until the physician changes their behavior.
Report the physician to the Chief Medical Officer for non-compliant documentation.
Ask the coding department to always code 'urosepsis' to the UTI code.
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 13: 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)
N - Not present at time of admission
W - Clinically undeterminable
Y - Yes, present at time of admission

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 14: 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 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
The SSI is coded with POA=Y to avoid payment reduction
The SSI code is excluded from the claim entirely to avoid payment penalty

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 15: For DRG reimbursement purposes, which comorbid condition most significantly increases the complexity of a pressure ulcer admission?

Hypertension
Mild anemia
Vitamin D deficiency
Osteomyelitis underlying the pressure ulcer (Correct answer)

Correct answer: Osteomyelitis underlying the pressure ulcer

Osteomyelitis underlying a pressure ulcer is a major complication/comorbidity (MCC) that can shift the DRG to a significantly higher-paying tier.

Question 16: HIPAA is relevant to CDI practice primarily in that it:

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
Prohibits CDI specialists from sending queries to physicians in paper form
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 17: Which approach BEST supports CDI success in capturing malnutrition documentation?

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

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

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

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 19: A patient is admitted with a heel wound that has been present for two months. The physician documents 'heel ulcer, etiology unclear.' What should the CDI specialist do?

Default to diabetic foot ulcer if the patient has diabetes
Query the physician to clarify whether it is a pressure ulcer, arterial ulcer, diabetic ulcer, or other type (Correct answer)
Leave the code unspecified as the physician's documentation is sufficient
Code it as a pressure ulcer based on the wound's location

Correct answer: Query the physician to clarify whether it is a pressure ulcer, arterial ulcer, diabetic ulcer, or other type

Etiology drives ICD-10-CM code selection for heel wounds, so the CDI specialist must query for clarification to ensure accurate coding and appropriate DRG assignment.

Question 20: For a patient undergoing coronary artery bypass graft (CABG), which documentation elements are essential for ICD-10-PCS procedure coding?

Surgeon attestation and operative time only
Post-operative ejection fraction measurement
Number of vessels bypassed only
Number of vessels bypassed and type of conduit used (Correct answer)

Correct answer: Number of vessels bypassed and type of conduit used

CABG procedure codes in ICD-10-PCS require documentation of both the number of coronary arteries bypassed and the conduit type (arterial, venous, or combination) to assign the correct code.

Question 21: 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 querying to link the MI to the previous pneumonia admission.
By changing the principal diagnosis of the first admission to something other than pneumonia.
By ensuring documentation clearly supports that the MI is an unrelated, new problem, making it a distinct admission. (Correct answer)
By documenting the readmission as 'planned' in the physician's notes.

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.

Question 22: What is the financial impact to a hospital if a patient acquires a Stage 3 pressure ulcer (a HAC) during their stay?

The entire claim is denied.
The DRG is paid as if the HAC was not present. (Correct answer)
There is no financial impact, it only affects quality scores.
The hospital receives a quality bonus.

Correct answer: The DRG is paid as if the HAC was not present.

Under the HAC Reduction Program, if a condition on the HAC list is acquired during the stay (POA = N or U), the DRG is recalculated for payment as if that secondary diagnosis were not present. This typically results in assignment to a lower-weighted and lower-paying DRG.

Question 23: A patient with suspected infection has a serum lactate of 3.2 mmol/L but no hypotension. How should the CDI specialist query this?

Query for septic shock because lactate ≥2 mmol/L meets the definition even without hypotension (Correct answer)
Query for septic shock because lactate alone defines it
Query for sepsis only, as hypotension is required for septic shock
No query is needed; elevated lactate is not a sepsis criterion

Correct answer: Query for septic shock because lactate ≥2 mmol/L meets the definition even without hypotension

Septic shock under Sepsis-3 can be diagnosed when lactate >2 mmol/L persists despite adequate resuscitation, even without hypotension.

Question 24: Which ICD-10-CM code correctly captures AKI requiring dialysis when no specific underlying etiology is documented?

N17.9
N19
N18.6
N17.0 (Correct answer)

Correct answer: N17.0

N17.0 is Acute kidney failure with tubular necrosis, but when dialysis is required without specific morphology noted, N17.9 (AKI unspecified) with a Z99.2 code for dialysis dependence is more appropriate; however, among these choices N17.0 reflects the most common documented etiology prompting dialysis.

Question 25: Under ICD-10-PCS, which character position represents the body part in a Medical and Surgical section procedure?

Character 3
Character 4 (Correct answer)
Character 6
Character 5

Correct answer: Character 4

In ICD-10-PCS Medical and Surgical section, character 4 represents the body part involved in the procedure.

Question 26: Which ICD-10-PCS root operation is used when a surgeon removes a kidney stone using an endoscope introduced through the urethra?

Fragmentation
Extirpation (Correct answer)
Excision
Extraction

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 27: ICD-10-CM guideline Section I.C.19 covers coding for injuries. When multiple injuries are present, what guides principal diagnosis selection?

Sequence the injury requiring the most surgical intervention as principal
The most serious injury, as determined by the provider, guides sequencing (Correct answer)
Always sequence the most severe injury as principal
The injury listed first in the operative report is principal

Correct answer: The most serious injury, as determined by the provider, guides sequencing

When multiple injuries are present, the most serious injury as determined by the provider is sequenced as the principal diagnosis.

Question 28: A CDI specialist documents in the query that clarifying a diagnosis to 'acute kidney injury' will increase reimbursement by $4,000. This practice is:

Compliant because transparency about reimbursement supports accurate coding
Non-compliant because queries must not reference financial impact or DRG changes (Correct answer)
Compliant if the physician is also informed of the clinical rationale
Non-compliant only if the amount exceeds $1,000 under OIG guidelines

Correct answer: Non-compliant because queries must not reference financial impact or DRG changes

Including financial impact or DRG information in a query is non-compliant and can constitute improper influence on physician documentation.

Question 29: 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 most expensive procedure performed is always the principal 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 colonoscopy is the principal procedure because it is an invasive 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 30: 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?

Disregard the query response and code based on the earlier note
Accept the query response and code the new diagnosis immediately
Escalate directly to the compliance department without notifying the physician
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 31: When coding a patient who develops ventilator-associated pneumonia (VAP) during an ICU stay, which ICD-10-CM code is assigned?

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

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 32: When a patient meets Sepsis-3 criteria and also has acute respiratory failure, what is the correct coding approach?

Code acute respiratory failure first, then sepsis
Code sepsis as principal and acute respiratory failure as an additional diagnosis (Correct answer)
Code R65.20 (Severe sepsis) which captures respiratory failure implicitly
Code only sepsis; respiratory failure is integral

Correct answer: Code sepsis as principal and acute respiratory failure as an additional diagnosis

ICD-10-CM guidelines direct coders to assign additional codes for any associated acute organ dysfunction, including acute respiratory failure, alongside the sepsis code.

Question 33: A patient is on a ventilator for 6 days. On day 7, the family decides to withdraw care, and the physician documents 'terminal extubation'. Why is this documentation important?

It allows the hospital to bill for an extra day of ventilator management.
It is the only way to stop the clock for counting ventilator days.
It is required for the death certificate.
It differentiates withdrawal of care from a failed weaning attempt, which can impact quality metrics. (Correct answer)

Correct answer: It differentiates withdrawal of care from a failed weaning attempt, which can impact quality metrics.

The term 'terminal extubation' or 'terminal wean' clarifies that the removal from the ventilator is part of the end-of-life process, not a failure to wean or a reflection of the quality of care. This distinction is important for quality metrics and accurately portraying the clinical circumstances.

Question 34: A patient undergoes a laparoscopic cholecystectomy that is converted to an open procedure. How should this be coded in ICD-10-PCS?

Code both the laparoscopic and open approaches with separate PCS codes
Code the procedure as percutaneous endoscopic converted to open with a single code
Code only the open approach since it was the completed procedure (Correct answer)
Code only the laparoscopic approach since it was the intended approach

Correct answer: Code only the open approach since it was the completed procedure

Per ICD-10-PCS guidelines, when a procedure is converted from a laparoscopic to an open approach, only the open approach procedure code is assigned. The laparoscopic portion that did not complete the intended procedure is not separately coded.

Question 35: A quality analyst reports that the hospital's risk-adjusted complication rate appears elevated compared to peers. What CDI-related factor should be investigated first?

Whether nursing documentation matches physician notes
Whether POA indicators are being assigned accurately for all secondary diagnoses (Correct answer)
Whether physicians are using electronic order sets
Whether the hospital is billing for all procedures performed

Correct answer: Whether POA indicators are being assigned accurately for all secondary diagnoses

Inaccurate POA indicator assignment can cause conditions present before admission to be counted as hospital-acquired complications, artificially inflating the risk-adjusted complication rate.

Question 36: Which type of AKI etiology is most commonly associated with contrast-induced nephropathy?

Functional AKI from low cardiac output
Post-renal AKI from urinary obstruction
Intrinsic (intrarenal) AKI from tubular injury (Correct answer)
Pre-renal AKI due to volume depletion

Correct answer: Intrinsic (intrarenal) AKI from tubular injury

Contrast-induced nephropathy causes direct tubular cell injury, classifying it as intrinsic (intrarenal) AKI rather than pre-renal or post-renal.

Question 37: 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?

Only the vancomycin trough levels
Whether the patient has underlying CKD
Documentation of the MRSA source only
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 38: Under ICD-10-PCS guidelines, which procedure is defined as the 'principal procedure' for DRG grouping purposes?

The procedure performed by the attending physician, regardless of complexity
The procedure with the highest ICD-10-PCS relative weight
The procedure most related to the principal diagnosis and most resource-intensive (Correct answer)
The first procedure listed in the operative report

Correct answer: The procedure most related to the principal diagnosis and most resource-intensive

The principal procedure is the one most related to the principal diagnosis or the one performed for definitive treatment. When multiple procedures are performed, the one most closely related to the principal diagnosis and involving the most resources is typically selected.

Question 39: Which of the following best describes the 'non-OR procedure affecting MS-DRG assignment' designation?

Procedures performed outside the OR that are ignored by the grouper
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

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 40: A CDS reviews a record with clinical indicators of sepsis (fever, tachycardia, leukocytosis, and a positive blood culture) but the physician has only documented 'UTI'. Which query statement is the most compliant?

Please document sepsis as it is clearly supported by the clinical evidence in the chart.
Do you agree the patient has sepsis secondary to UTI based on the fever, tachycardia, and positive blood culture?
Based on the documented fever, tachycardia, leukocytosis, and positive blood culture, can you please clarify a diagnosis that represents these findings? (Correct answer)
Per sepsis-3 criteria, this patient meets the definition. Please clarify the diagnosis.

Correct answer: Based on the documented fever, tachycardia, leukocytosis, and positive blood culture, can you please clarify a diagnosis that represents these findings?

This query is compliant because it presents the objective clinical indicators from the record and asks the physician to provide a diagnosis based on their professional judgment without leading them to a specific answer. Options A and C are leading, and option B introduces information not present in the scenario.

Question 41: 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:

Replacement (Correct answer)
Resection
Reposition
Repair

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 42: 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 sent only retrospectively after final coding is complete to avoid influencing care decisions
A verbal query documented only in the CDI specialist's personal notes, not in the medical record
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)

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 43: Which diagnosis has a POA indicator exempt status and does not require POA reporting?

External cause codes (V, W, X, Y codes) for injuries (Correct answer)
Ventilator-associated pneumonia
Hospital-acquired pressure ulcers
Deep vein thrombosis (DVT)

Correct answer: External cause codes (V, W, X, Y codes) for injuries

External cause codes (ICD-10-CM V, W, X, Y codes) are exempt from POA reporting requirements. These codes describe circumstances of injury such as falls or motor vehicle accidents.

Question 44: When auditing coded data for PSI (Patient Safety Indicator) accuracy, a CDS specialist should focus most on the distinction between:

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

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 45: Which Joint Commission standard most directly addresses the completeness of medical record documentation?

PC.01.02.01 — Patient assessment standards
MM.01.01.03 — Medication management documentation
LD.04.01.01 — Leadership accountability standards
RC.01.01.01 — Medical record content and completion requirements (Correct answer)

Correct answer: RC.01.01.01 — Medical record content and completion requirements

RC.01.01.01 requires that the medical record contain sufficient information to identify the patient, support the diagnosis, and justify the treatment.

Question 46: A CDS specialist identifies a statistically significant correlation (r = 0.82) between query volume and CMI improvement. What is the most important caveat to communicate when presenting this finding?

The r-value is too low to be meaningful
Query volume should be reduced to test the relationship
Correlation does not imply causation (Correct answer)
CMI is not a valid outcome measure

Correct answer: Correlation does not imply causation

Even a strong correlation cannot confirm that increased queries caused CMI improvement without controlling for confounding variables.

Question 47: A CDI analyst notices CMI increased coinciding with a new CDI program implementation. Which additional data point would BEST confirm that CDI activities drove the CMI improvement?

Physician credentialing records showing new specialist hires
Hospital bed expansion records from the same period
CC/MCC capture rate and query impact data from CDI tracking software (Correct answer)
Total Medicare discharge volume for both years

Correct answer: CC/MCC capture rate and query impact data from CDI tracking software

CC/MCC capture rate changes and CDI query impact data directly link documentation improvements to the CMI increase.

Question 48: Which of the following represents the BEST practice for a CDI specialist when a physician's query response is received after the claim has already been submitted?

Discard the query response since the claim is already submitted
Retroactively change the DRG without amending the medical record
File the response as an addendum but do not update the coded claim
Work with coding and billing to amend the claim if the response changes the coded diagnoses (Correct answer)

Correct answer: Work with coding and billing to amend the claim if the response changes the coded diagnoses

If a physician query response changes the diagnosis coding after claim submission, the appropriate action is to amend the medical record with the physician's addendum and work with coding and billing to submit a corrected claim.

Question 49: What is the clinical documentation and reimbursement significance of 'acute on chronic heart failure'?

It is not a recognized ICD-10-CM diagnostic term
It results in a lower DRG weight due to chronic disease adjustment
It has no reimbursement impact compared to chronic heart failure
It carries a higher DRG weight than chronic heart failure alone and has its own specific ICD-10-CM code (Correct answer)

Correct answer: It carries a higher DRG weight than chronic heart failure alone and has its own specific ICD-10-CM code

Acute on chronic heart failure has a specific ICD-10-CM code and typically results in a higher-weighted DRG compared to chronic heart failure alone, reflecting the increased resource utilization.

Question 50: What is the ICD-10-CM convention for coding a condition that is integral to a disease process?

It is coded with an additional external cause code
It is not coded separately, as it is inherent to the condition (Correct answer)
It is sequenced as the principal diagnosis
It is coded separately with a note indicating it is integral

Correct answer: It is not coded separately, as it is inherent to the condition

ICD-10-CM Guideline Section I.B.5 states that signs and symptoms that are integral to a disease process should not be assigned as additional codes unless otherwise instructed by the classification.

Question 51: Which documentation element is most critical when a physician records 'cardiomegaly' on imaging but the clinical note mentions 'dilated cardiomyopathy'?

Code only cardiomegaly as it is the radiological finding
Query to clarify whether cardiomegaly is a separate finding or the result of dilated cardiomyopathy (Correct answer)
Ignore cardiomegaly and code only dilated cardiomyopathy
Code both diagnoses separately as they are distinct conditions

Correct answer: Query to clarify whether cardiomegaly is a separate finding or the result of dilated cardiomyopathy

CDI specialists must query when imaging findings and clinical diagnoses conflict or overlap to ensure accurate and complete coding.

Question 52: When analyzing CC/MCC capture rates by physician, a CDI analyst finds that one physician has a significantly lower capture rate than peers. What is the MOST appropriate next step?

Compare the physician's patient volume to peers before drawing conclusions
Conduct a focused chart review to determine if documentation gaps or coding issues are the cause (Correct answer)
Remove the physician from CDI monitoring
Immediately report the physician to compliance

Correct answer: Conduct a focused chart review to determine if documentation gaps or coding issues are the cause

Before taking any action, the CDI analyst should conduct a focused review of the physician's charts to determine whether the low capture rate reflects documentation deficiencies, a legitimately less-complex patient mix, or coding issues.

Question 53: Which CMS program specifically audits hospital inpatient coding accuracy on a post-payment basis and can demand repayment of improper Medicare payments?

Medicare Administrative Contractor (MAC) pre-payment review
Comprehensive Error Rate Testing (CERT)
Quality Improvement Organization (QIO) review
Recovery Audit Contractor (RAC) program (Correct answer)

Correct answer: Recovery Audit Contractor (RAC) program

Recovery Audit Contractors review Medicare claims after payment and issue demand letters for overpayments identified through improper coding.

Question 54: Which statistical measure is most appropriate for describing the central tendency of a skewed distribution of patient length-of-stay data?

Mean
Median (Correct answer)
Mode
Range

Correct answer: Median

The median is preferred over the mean for skewed distributions because it is not distorted by extreme outliers.

Question 55: Which situation would be MOST appropriate for a concurrent CDI review strategy rather than retrospective review?

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

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

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

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 57: Which federal agency is responsible for maintaining and updating the ICD-10-CM code set?

The Department of Veterans Affairs (VA)
The American Hospital Association (AHA)
CMS and the National Center for Health Statistics (NCHS) (Correct answer)
The American Health Information Management Association (AHIMA)

Correct answer: CMS and the National Center for Health Statistics (NCHS)

ICD-10-CM is maintained jointly by CMS and the National Center for Health Statistics (NCHS), a division of the CDC. CMS maintains ICD-10-PCS for the procedural code set used in inpatient settings.

Question 58: 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
The complication that developed during the stay
Encounter for antineoplastic chemotherapy (Z51.11) (Correct answer)
The malignancy for which chemotherapy is being administered

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 59: A patient is admitted for an open femur fracture and undergoes an open reduction internal fixation (ORIF). During the hospital stay, they develop respiratory failure and require an emergency intubation and mechanical ventilation. What is the principal procedure?

Mechanical ventilation.
There are two principal procedures in this case.
Intubation, because it was life-saving.
Open reduction internal fixation (ORIF). (Correct answer)

Correct answer: Open reduction internal fixation (ORIF).

The ORIF was performed to treat the principal diagnosis (femur fracture), which was the reason for the admission. The intubation was performed to treat a complication that arose later. Therefore, the ORIF is the principal procedure.

Question 60: A hospital's CDI program tracks 'query agreement rate.' A low agreement rate most likely indicates:

Queries are being sent without adequate clinical support or are poorly formulated (Correct answer)
Coders are not reviewing query responses before assigning codes
Physicians are confirming queried diagnoses at a high rate
The CDI program has an unusually complex patient population

Correct answer: Queries are being sent without adequate clinical support or are poorly formulated

A low query agreement rate where physicians frequently respond 'clinically undetermined' or disagree with the queried diagnosis suggests queries lack sufficient clinical support or are poorly constructed.

Question 61: Which MS-DRG grouping concept refers to a secondary diagnosis that increases the severity of illness and resource use, elevating DRG assignment?

Principal diagnosis
Hierarchical Condition Category (HCC)
Present on Admission (POA) indicator
Complication or Comorbidity (CC) (Correct answer)

Correct answer: Complication or Comorbidity (CC)

A Complication or Comorbidity (CC) or Major CC (MCC) is a secondary diagnosis that increases DRG weight and reimbursement under the IPPS system.

Question 62: Under AHIMA's 2019 compliant query guidelines, which of the following must be included in every written query?

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

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 63: What is "data validation" in the context of clinical documentation?

Ensuring that data meets quality and accuracy standards (Correct answer)
Converting data into different formats
The process of encrypting patient data
Archiving old patient records

Correct answer: Ensuring that data meets quality and accuracy standards

Data validation in clinical documentation refers to the process of ensuring that the recorded information is accurate, complete, consistent, and adheres to established quality standards. This involves checking for errors, inconsistencies, and missing data points to maintain the integrity and reliability of patient records. High-quality data is essential for accurate coding, billing, patient care, and research.

Question 64: Which CDI query approach is most appropriate when a patient presents with acute decompensated heart failure?

Query for the underlying cause of decompensation (Correct answer)
No query is needed if heart failure is already documented
Query only for NYHA functional classification
Query for fluid overload as an additional diagnosis

Correct answer: Query for the underlying cause of decompensation

Querying for the underlying cause of decompensation (e.g., medication noncompliance, new MI, dietary indiscretion) provides specificity that impacts DRG assignment and quality metrics.

Question 65: A patient is admitted for acute MI and subsequently develops heart failure during the stay. What is the correct principal diagnosis?

Heart failure, because it was the more complex condition
Either may be principal at the physician's discretion
Acute MI, because it was the condition prompting admission (Correct answer)
Both are listed but neither is designated as principal

Correct answer: Acute MI, because it was the condition prompting admission

When acute MI precipitates heart failure, the acute MI remains the principal diagnosis as the condition that established the need for admission.

Question 66: Under the Outpatient Code Editor (OCE), which edit would cause a claim to be returned to a provider for correction?

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

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 67: A patient with type 2 diabetes mellitus is documented with CKD Stage 3b. What is the correct ICD-10-CM coding approach?

Assign only E11.9 since diabetes is the underlying cause
Assign only N18.32 since CKD is the complicating condition
Assign E11.22 for diabetic chronic kidney disease plus N18.32 for the specific CKD stage (Correct answer)
Assign E11.9 and N18.32 as unrelated diagnoses

Correct answer: Assign E11.22 for diabetic chronic kidney disease plus N18.32 for the specific CKD stage

ICD-10-CM requires E11.22 (type 2 DM with diabetic CKD) paired with N18.32 (CKD Stage 3b) to capture both the diabetic etiology and the specific stage of CKD.

Question 68: In ICD-10-PCS, which root operation is used to code the insertion of a cardiac pacemaker generator into the chest wall?

Supplement
Replacement
Fusion
Insertion (Correct answer)

Correct answer: Insertion

Insertion is the ICD-10-PCS root operation for putting in a nonbiological device that monitors, assists, performs, or prevents a physiological function.

Question 69: A patient is admitted with chest pain. After a full workup, myocardial infarction is ruled out, and the physician determines the cause of the chest pain to be gastroesophageal reflux disease (GERD). According to UHDDS guidelines, what is the principal diagnosis?

Gastroesophageal reflux disease (GERD) (Correct answer)
Unspecified cardiac condition
Chest pain
Acute myocardial infarction

Correct answer: Gastroesophageal reflux disease (GERD)

The principal diagnosis is defined as the condition established after study to be chiefly responsible for occasioning the admission of the patient to the hospital for care. In this case, GERD was the final diagnosis determined to be the cause of the admission.

Question 70: In a clinical data quality audit, a CDS specialist finds that 15% of records lack a principal diagnosis. This metric is best classified as a measure of:

Data reliability
Data validity
Data timeliness
Data completeness (Correct answer)

Correct answer: Data completeness

Completeness measures whether required data elements are present in the record.

Question 71: 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:

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

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 72: Which scenario represents an APPROPRIATE use of a retrospective query?

Querying after discharge solely to upgrade the DRG to improve hospital reimbursement
Querying to add a secondary diagnosis already captured and coded during the concurrent review
Querying after discharge when clinical indicators in the record suggest a condition that was never explicitly documented (Correct answer)
Querying a physician to change a diagnosis that a coder personally disagrees with

Correct answer: Querying after discharge when clinical indicators in the record suggest a condition that was never explicitly documented

Retrospective queries are appropriate when the medical record contains clinical evidence of an undocumented condition affecting coding accuracy.

Question 73: Which of the following ICD-10-PCS sections is used to code procedures on peripheral veins?

Section 3 - Administration
Section 0 - Medical and Surgical (Correct answer)
Section 2 - Placement
Section 5 - Extracorporeal or Systemic Assistance

Correct answer: Section 0 - Medical and Surgical

The Medical and Surgical section (Section 0) of ICD-10-PCS covers all surgical procedures on anatomical body parts including peripheral veins.

Question 74: When a nephrologist documents 'worsening renal function' without a specific diagnosis, what is the CDI specialist's most appropriate response?

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

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 75: In the context of present on admission (POA) indicators, which condition would be assigned a POA indicator of 'N'?

A pressure injury that developed two days after admission (Correct answer)
A fracture that was the reason for admission
Chronic hypertension noted in the history and physical
A UTI documented at the time of admission

Correct answer: A pressure injury that developed two days after admission

A POA indicator of 'N' is assigned when the condition was not present at the time of admission, such as a hospital-acquired condition.

Question 76: Which CDI metric measures the percentage of admitted cases that receive a CDI review?

Concurrent review rate
Penetration rate (Correct answer)
Query rate
CMI capture rate

Correct answer: Penetration rate

Penetration rate measures the percentage of total eligible admissions that receive a CDI review. A higher penetration rate indicates broader CDI coverage across the patient population.

Question 77: What is a critical requirement for documenting a verbal query?

The CDS must send a follow-up email to the physician summarizing the conversation.
The CDS must record the conversation on a mobile device for future reference.
The CDS should simply remember the conversation and inform the coder of the physician's answer.
The CDS must document the question, clinical indicators, and the physician's response in the health record for the physician to sign. (Correct answer)

Correct answer: The CDS must document the question, clinical indicators, and the physician's response in the health record for the physician to sign.

For a verbal interaction to be considered a compliant query, it must be documented in the permanent health record. This documentation should include the question asked, the clinical indicators discussed, the physician's response, and the date/time, followed by the physician's signature or attestation.

Question 78: 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 79: Which documented condition, if present alongside AKI, would most likely result in an MS-DRG upgrade reflecting greater patient resource intensity?

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

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

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

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 81: When two surgical procedures are performed and either could serve as the principal procedure, what does the UHDDS guideline recommend?

Select the procedure with the higher relative weight
Always select the procedure with the longer operative time
Code both and let the grouper decide automatically
The facility may sequence them in any order, and the grouper selects the DRG with the highest weight (Correct answer)

Correct answer: The facility may sequence them in any order, and the grouper selects the DRG with the highest weight

UHDDS guidelines allow facilities to sequence multiple qualifying procedures in any order; the MS-DRG grouper evaluates all coded procedures and assigns the DRG that results in the highest relative weight.

Question 82: Which CKD stage corresponds to a GFR of 15–29 mL/min/1.73m²?

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

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 83: A patient admitted for a simple UTI (a low-mortality DRG) dies unexpectedly. A CDI review is initiated to assess for PSI 02 (Death in Low-Mortality DRGs). What is the most important documentation focus for the CDI specialist?

Confirming the patient's age and discharge disposition.
Verifying that the correct antibiotics were administered for the UTI.
Identifying and clarifying all active comorbidities and complications that increase the risk of mortality. (Correct answer)
Ensuring the documentation of the patient's code status (e.g., DNR).

Correct answer: Identifying and clarifying all active comorbidities and complications that increase the risk of mortality.

PSI 02 flags deaths in what are expected to be low-risk admissions. The key to accurately reflecting the patient's risk is to capture all co-existing, active secondary diagnoses that contribute to a higher risk of mortality, such as severe sepsis, acute respiratory failure, or metastatic cancer. This demonstrates the patient was sicker than the principal diagnosis alone would suggest.

Question 84: HCC risk adjustment is primarily used in which payment model?

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

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 85: A CDS program wants to benchmark its query response rate against national standards. Which data source would provide the most relevant external comparison?

ACDIS CDI industry survey benchmarks (Correct answer)
State vital statistics records
CMS cost reports
Internal facility historical data

Correct answer: ACDIS CDI industry survey benchmarks

ACDIS publishes annual CDI industry surveys that provide national benchmarks for query response and agreement rates.

Question 86: Which staging system provides the basis for ICD-10-CM pressure injury code assignment?

National Pressure Injury Advisory Panel (NPIAP) staging (Correct answer)
PUSH Tool measurement
Braden Scale score
Wagner Grading System

Correct answer: National Pressure Injury Advisory Panel (NPIAP) staging

ICD-10-CM pressure ulcer codes are structured around the NPIAP staging system (Stage 1–4, unstageable, and deep tissue pressure injury).

Question 87: 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 valid as long as it is signed by the attending physician within 48 hours of submission
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 clinically valid when it results in an increased MS-DRG weight

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 88: What is the primary risk of using 'leading' language in a physician query?

It can be seen by auditors as introducing information to artificially inflate reimbursement. (Correct answer)
It may confuse the physician, leading to an incorrect response.
It is against hospital policy but has no external regulatory implications.
It often results in lower query response rates from providers.

Correct answer: It can be seen by auditors as introducing information to artificially inflate reimbursement.

Leading queries can be interpreted as introducing new information or influencing the physician's response, which could be viewed as evidence of a false claim by auditors. This undermines the integrity of the health record and can have significant legal and financial repercussions.

Question 89: Which metric directly measures the financial impact of a CDS program on hospital reimbursement?

Average length of stay
Complication and comorbidity (CC/MCC) capture rate (Correct answer)
Query response rate
Readmission rate

Correct answer: Complication and comorbidity (CC/MCC) capture rate

The CC/MCC capture rate reflects how often higher-severity diagnoses are documented, directly affecting MS-DRG assignment and reimbursement.

Question 90: What is the role of a Clinical Documentation Specialist (CDS) in relation to clinical coding?

To provide patient financial assistance
To handle administrative tasks unrelated to clinical documentation
To manage patient care directly
To ensure that clinical documentation supports accurate coding and billing (Correct answer)

Correct answer: To ensure that clinical documentation supports accurate coding and billing

A Clinical Documentation Specialist (CDS) plays a vital role in ensuring that clinical documentation accurately and completely supports the clinical codes assigned for billing and data analysis. They review patient records to identify any gaps or inconsistencies that could lead to incorrect coding. By querying physicians for clarification, the CDS helps to ensure that the documentation reflects the true severity of illness and complexity of care, thereby optimizing coding accuracy and reimbursement.

Question 91: A hospital notices its observed mortality rate is significantly higher than the expected rate for pneumonia patients. The CDI manager suspects documentation deficiency. What is the MOST likely gap?

Attending physicians are not signing discharge summaries within required timeframes
The hospital is admitting more patients from long-term care facilities
Pneumonia type is not specified
Secondary diagnoses that capture patient complexity are not being documented (Correct answer)

Correct answer: Secondary diagnoses that capture patient complexity are not being documented

When observed mortality exceeds expected mortality, it often indicates that secondary diagnoses reflecting patient complexity such as MCCs are not being documented. Without these diagnoses, the risk-adjustment model underestimates expected mortality.

Question 92: A CDI specialist notices a physician documents 'urosepsis' in the record. Under ICD-10-CM coding guidelines, the appropriate next step is to:

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

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 93: Under ICD-10-CM Official Guidelines, when a patient is admitted for a complication of a previous surgery performed at another facility, what is the principal diagnosis?

The reason the patient sought care at the current facility
The original condition that required surgery
The surgical procedure performed at the other facility
The postoperative complication itself (Correct answer)

Correct answer: The postoperative complication itself

The postoperative complication is coded as the principal diagnosis when the patient is admitted specifically to treat that complication.

Question 94: Which key performance indicator (KPI) is often used to assess the quality of clinical documentation?

Average daily census
Number of patient complaints
Patient length of stay
Documentation accuracy rate (Correct answer)

Correct answer: Documentation accuracy rate

Documentation accuracy rate is a key performance indicator (KPI) directly used to assess the quality of clinical documentation. It measures the percentage of records that are complete, consistent, and accurately reflect the patient's condition and care provided. A high accuracy rate indicates effective documentation practices, which are crucial for patient safety, appropriate billing, and reliable data for healthcare analytics.

Question 95: Which quality metric measures the rate of complications that could reasonably have been prevented through optimal care?

Average Length of Stay (ALOS)
Geometric Mean Length of Stay (GMLOS)
Patient Safety Indicators (PSIs) (Correct answer)
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 96: Under ICD-10-CM POA reporting guidelines, which category of codes is EXEMPT from POA indicator reporting?

Secondary diagnosis codes that affect DRG assignment
Principal diagnosis codes
Codes for chronic conditions
External cause codes (Correct answer)

Correct answer: External cause codes

External cause codes (V, W, X, Y codes) are exempt from POA indicator reporting per ICD-10-CM official guidelines.

Question 97: A patient undergoes percutaneous transluminal coronary angioplasty (PTCA) with stent placement and also receives a pacemaker insertion during the same admission. How does this affect MS-DRG assignment?

The two procedures cancel each other out and a medical DRG is assigned
PTCA takes precedence because it was performed first
Only the pacemaker insertion is used because it has the higher relative weight
Both procedures are coded; the grouper selects the DRG that optimally captures the resource use (Correct answer)

Correct answer: Both procedures are coded; the grouper selects the DRG that optimally captures the resource use

The MS-DRG grouper evaluates all coded OR procedures and assigns the DRG combination that best reflects the resource intensity of the admission.

Question 98: During a CDI review, a patient is noted to have a tracheostomy placed on day 4 of mechanical ventilation. What CDI consideration applies?

Only hours after tracheostomy count toward ventilation duration
Tracheostomy eliminates the need for ventilation duration coding
The pre-tracheostomy ventilator hours and post-tracheostomy hours are combined for duration coding (Correct answer)
Tracheostomy placement resets the mechanical ventilation duration clock

Correct answer: The pre-tracheostomy ventilator hours and post-tracheostomy hours are combined for duration coding

ICD-10-PCS guidelines require totaling all hours of continuous mechanical ventilation, including time before and after tracheostomy, to determine duration code selection.

Question 99: 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?

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

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 100: A patient with chronic systolic heart failure undergoes implantation of a left ventricular assist device (LVAD) as destination therapy. How does this procedure affect DRG assignment?

It assigns the case to MDC 24 due to surgical complexity
It has no DRG impact since LVADs are not recognized by the MS-DRG grouper
It assigns the case to a pre-MDC surgical DRG for LVAD implantation, bypassing standard MDC grouping (Correct answer)
It assigns the case to MDC 5 with a standard heart failure DRG

Correct answer: It assigns the case to a pre-MDC surgical DRG for LVAD implantation, bypassing standard MDC grouping

LVAD implantation is a high-cost, resource-intensive procedure that is assigned to a pre-MDC DRG, reflecting the extraordinary resource utilization.

Question 101: When a CDI specialist queries a physician about a possible principal diagnosis change, the physician does not respond. What is the APPROPRIATE next step?

Code the diagnosis the CDI specialist believes is correct
Discard the query and finalize coding without the clarification
Follow the facility's escalation policy, which may include notifying a physician advisor (Correct answer)
Contact the patient directly to determine the correct diagnosis

Correct answer: Follow the facility's escalation policy, which may include notifying a physician advisor

Facilities should have escalation policies that include physician advisors or medical staff leadership to address non-responsive physicians.

Question 102: According to ICD-10-CM conventions, how are the terms 'acute kidney failure' and 'acute kidney injury' treated for coding purposes?

Acute kidney failure is coded only when the patient requires ICU-level care
Acute kidney failure applies only when GFR drops below 15 mL/min
Acute kidney failure requires dialysis while AKI does not
The terms are treated as equivalent and both are captured under the N17.x code category (Correct answer)

Correct answer: The terms are treated as equivalent and both are captured under the N17.x code category

ICD-10-CM treats 'acute kidney failure' and 'acute kidney injury' as clinically equivalent terms, both assigned to the N17.x category regardless of dialysis status.

Question 103: A patient with type 2 diabetes is admitted for a diabetic foot ulcer with peripheral angiopathy. What documentation is needed to capture the highest specificity?

Document only the ulcer since it is the reason for admission
Document diabetes and foot ulcer as separate, unrelated conditions
Document the causal relationship between diabetes, peripheral angiopathy, and the ulcer, including ulcer site and severity (Correct answer)
Document peripheral vascular disease without linking it to diabetes

Correct answer: Document the causal relationship between diabetes, peripheral angiopathy, and the ulcer, including ulcer site and severity

ICD-10-CM combination codes for diabetic complications require documented linkage between diabetes and the complication, plus ulcer site and severity for complete specificity.

Question 104: Under the False Claims Act (FCA), which of the following scenarios could create liability for a hospital's CDI program?

Using concurrent review to identify documentation gaps before discharge
Querying physicians about clinical indicators found in the medical record
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

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 105: Which OIG program provides annual guidance on high-risk healthcare compliance areas including CDI and coding?

Medicare Administrative Contractor (MAC) Local Coverage Determinations
CMS PEPPER reports
OIG Work Plan and annual compliance program guidance (Correct answer)
Recovery Audit Contractor (RAC) denial trend reports

Correct answer: OIG Work Plan and annual compliance program guidance

The OIG Work Plan, published annually, identifies high-risk areas for fraud and abuse including CDI-related issues such as inpatient admission criteria, DRG upcoding, and specific diagnosis documentation.

Question 106: A physician responds to a query by writing 'per CDI' next to a newly added diagnosis. The CDI specialist should:

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

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 107: Which of the following BEST describes the 'present on admission' (POA) query scenario?

A query to confirm the patient's preadmission medication list
A query to determine whether a condition requires treatment during the current hospitalization
A query asking whether a secondary diagnosis existed before or at the time of inpatient admission (Correct answer)
A query to establish the principal diagnosis for the current admission

Correct answer: A query asking whether a secondary diagnosis existed before or at the time of inpatient admission

POA queries ask the physician to clarify whether a condition was present at the time of inpatient admission or developed during the hospitalization.

Question 108: A coder encounters a diagnosis of 'probable pneumonia' documented by the attending physician on an inpatient record. How should this be coded?

Code only symptoms such as cough and fever
Query the physician before coding anything
Code as 'rule-out' pneumonia using a Z code
Code the pneumonia as confirmed (Correct answer)

Correct answer: Code the pneumonia as confirmed

For inpatient records, UHDDS guidelines allow coding of conditions documented as 'probable' or 'suspected' as if confirmed.

Question 109: A patient is admitted with sepsis and develops oliguria with creatinine rising from 0.9 to 2.4 mg/dL over 36 hours. The physician documents 'renal insufficiency.' What should the CDS do?

Query the physician to clarify if this meets criteria for acute kidney injury (Correct answer)
Code acute renal failure based on the creatinine values alone
Document acute tubular necrosis based on the clinical picture
Accept the documentation as sufficient for coding

Correct answer: Query the physician to clarify if this meets criteria for acute kidney injury

The CDS should query the physician because the creatinine rise of >1.5x baseline meets KDIGO criteria for AKI Stage 1, but 'renal insufficiency' is a nonspecific term not recognized as equivalent to AKI in ICD-10-CM.

Question 110: When evaluating the effectiveness of physician education sessions, which metric is the BEST indicator of sustained improvement?

Post-education query rate for the targeted diagnoses
Physician satisfaction survey scores from the education sessions
Number of physicians who attended education sessions
Pre- versus post-education CC/MCC capture rate trend over 6 or more months (Correct answer)

Correct answer: Pre- versus post-education CC/MCC capture rate trend over 6 or more months

Sustained improvement in CC/MCC capture rates over several months following education demonstrates actual behavioral change in physician documentation practices.

Question 111: Which of the following statements about query timing is MOST accurate under compliant query practices?

Queries must only be submitted after the patient is discharged to avoid influencing care
Queries are not permitted once a final bill has been submitted to the payer
Queries may be issued concurrently during the encounter or retrospectively after discharge (Correct answer)
Queries should be issued only at admission to capture the principal diagnosis early

Correct answer: Queries may be issued concurrently during the encounter or retrospectively after discharge

Both concurrent (during admission) and retrospective (post-discharge) queries are permissible under compliant query guidelines.

Question 112: Under ICD-10-PCS, which root operation describes surgically cutting a body part without draining fluids or removing tissue?

Drainage
Division (Correct answer)
Excision
Release

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

To change the principal diagnosis after the claim has already been submitted
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 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 114: Under ICD-10-PCS, what distinguishes 'Fusion' from 'Arthrodesis' in spinal procedure coding?

Fusion applies to cervical spine only; Arthrodesis applies to lumbar spine
ICD-10-PCS uses 'Fusion' as the root operation; 'Arthrodesis' is the clinical term for the same concept (Correct answer)
Fusion involves implantable devices while Arthrodesis does not
Fusion is an obsolete root operation replaced by Arthrodesis in ICD-10-PCS

Correct answer: ICD-10-PCS uses 'Fusion' as the root operation; 'Arthrodesis' is the clinical term for the same concept

In ICD-10-PCS the official root operation is Fusion; 'arthrodesis' is the clinical/surgical synonym that maps to the Fusion root operation.

Question 115: A Recovery Audit Contractor (RAC) denies payment for a sepsis claim. What is the FIRST step in the appeals process?

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

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 116: 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 query process may be leading or financially motivated, warranting a compliance review (Correct answer)
The hospital's payer mix likely skews toward more complex patients

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

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

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 118: What does the clinical term 'acute-on-chronic kidney disease' indicate for ICD-10-CM coding purposes?

A patient with CKD who has never experienced an acute kidney episode
CKD that has recently advanced to a higher stage without an acute episode
AKI superimposed on pre-existing CKD, requiring codes for both conditions (Correct answer)
A temporary improvement in CKD function following treatment

Correct answer: AKI superimposed on pre-existing CKD, requiring codes for both conditions

Acute-on-chronic kidney disease indicates AKI has developed in a patient with underlying CKD; ICD-10-CM requires assigning codes for both AKI (N17.x) and the appropriate CKD stage (N18.x).

Question 119: When is a verbal physician query considered acceptable under CDI compliance standards?

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)
For all queries, as verbal communication is faster and more efficient
For routine coding clarifications that do not affect DRG assignment

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

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

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 121: 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
Verify the written-in diagnosis is supported by the clinical documentation before coding it (Correct answer)
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

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 122: A CDI specialist notices a patient was admitted with sepsis but the physician only documented 'fever and hypotension.' What is the BEST initial CDI strategy?

Leave the documentation as-is to avoid bothering the physician
Submit a query asking the physician to clarify whether sepsis is present based on the clinical indicators (Correct answer)
Report the case to compliance for incomplete documentation
Assign the sepsis code based on the clinical evidence without querying

Correct answer: Submit a query asking the physician to clarify whether sepsis is present based on the clinical indicators

CDI specialists should submit a compliant query when clinical indicators support a more specific diagnosis that the physician has not explicitly documented.

Question 123: A patient with severe heart failure has significant peripheral edema and ascites. How does this affect malnutrition assessment and documentation?

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

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

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

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 125: 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 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)
Code elevated troponin as the principal diagnosis

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 126: A patient's discharge summary documents 'acute renal failure' and the medical record contains clinical evidence supporting KDIGO Stage 2 AKI. What is the appropriate CDI action?

Assign the lowest AKI stage to remain conservative in documentation
Code acute renal failure (N17.9) without further clarification
Query the physician to specify the AKI stage for more accurate and specific code assignment (Correct answer)
Disregard staging since it does not affect reimbursement

Correct answer: Query the physician to specify the AKI stage for more accurate and specific code assignment

Querying the physician to specify the AKI stage enables more precise ICD-10-CM code assignment, which may affect CC/MCC classification and MS-DRG weight.

Question 127: 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 bacteremia; Sepsis-3 does not
There is no difference; ICD-10-CM updated to mirror Sepsis-3 in 2017
ICD-10-CM severe sepsis requires a SOFA score ≥4; Sepsis-3 uses ≥2
Sepsis-3 eliminated the term 'severe sepsis'; ICD-10-CM retains it for coding purposes (Correct answer)

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 128: Which documentation standard requires that every medical record entry be dated, timed, and authenticated by the responsible provider?

CMS MS-DRG Definitions Manual
ICD-10-CM Official Coding Guidelines
The Joint Commission (TJC) Medical Record Standards (Correct answer)
AHIMA Standards of Ethical Coding

Correct answer: The Joint Commission (TJC) Medical Record Standards

The Joint Commission's medical record standards require that all entries in the medical record be dated, timed, and authenticated (signed) by the responsible provider.

Question 129: A patient develops sepsis 72 hours after hip arthroplasty. Which POA indicator applies to the sepsis diagnosis?

Y – present on admission
N – not present on admission (Correct answer)
U – documentation insufficient to determine
W – clinically undetermined

Correct answer: N – not present on admission

Sepsis developing 72 hours post-admission was not present on admission and should be assigned POA indicator 'N'.

Question 130: A patient on mechanical ventilation has a tracheostomy placed on day 5 of ventilation. The patient continues on the vent for a total of 14 days before being weaned. Which ICD-10-PCS codes are required?

One code for extended mechanical ventilation; tracheostomy is included in the vent code
Codes for both the tracheostomy procedure and mechanical ventilation performance (Correct answer)
No PCS codes are needed; mechanical ventilation is coded only through diagnosis codes
One code for tracheostomy only; mechanical ventilation is a nursing procedure not coded in PCS

Correct answer: Codes for both the tracheostomy procedure and mechanical ventilation performance

Both the tracheostomy procedure and mechanical ventilation performance require separate ICD-10-PCS codes. The tracheostomy is coded from the Medical and Surgical section, and mechanical ventilation is coded from Section 5.

Question 131: A patient is admitted with AKI and recovers renal function before discharge. The discharge summary states 'resolved AKI.' How should this be coded?

Code AKI as a secondary diagnosis because it was present and treated during the encounter (Correct answer)
Code as history of AKI using a Z code
Code only the underlying cause of the AKI
Do not code AKI since it resolved before discharge

Correct answer: Code AKI as a secondary diagnosis because it was present and treated during the encounter

Conditions that are diagnosed and treated during the hospitalization are coded even if resolved at discharge, as they affected patient care and management during the encounter.

Question 132: During a concurrent review, a CDIS notes the physician documented 'acute respiratory failure' on hospital day 3 with no mention in the H&P. The patient was admitted for COPD exacerbation. What should the CDIS do?

Leave the POA indicator blank as it is a complication of a POA diagnosis
Assign POA indicator 'Y' because COPD was present on admission
Assign POA indicator 'N' because it was documented after admission
Query the physician to clarify whether the acute respiratory failure was present on admission (Correct answer)

Correct answer: Query the physician to clarify whether the acute respiratory failure was present on admission

A CDIS should query the physician to clarify clinical timing before assigning a POA indicator for a condition first documented after admission.

Question 133: 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: Whipple procedure
Principal diagnosis: pancreatitis; principal procedure: Whipple procedure (Correct answer)
Principal diagnosis: pancreatic mass; principal procedure: biopsy only

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

The condition is included in the code and should not be coded separately
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 excluded code may be used together with the code it is excluded from

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 135: When tracking CDI program performance, which trend would indicate a PROBLEM with query compliance?

A consistently high rate of 'unable to determine' physician responses to queries (Correct answer)
Increasing case mix index over successive quarters
A high rate of physician agreement with CDI query options
Decreasing length of stay with stable documentation quality scores

Correct answer: A consistently high rate of 'unable to determine' physician responses to queries

A high rate of 'unable to determine' responses may indicate that queries are being issued without sufficient clinical evidence to support the queried diagnosis.

Question 136: A patient is admitted with acute-on-chronic systolic heart failure and hypertensive heart disease. Which ICD-10-CM code set correctly captures this combination?

I13.0 and I50.21 (Correct answer)
I11.0 and I50.21
I50.21 and I13.0
I11.0 and I50.9

Correct answer: I13.0 and I50.21

ICD-10-CM code I13.0 combines hypertensive heart disease with heart failure, and I50.21 specifies the acute-on-chronic systolic type, per combination code guidelines.

Question 137: When querying about the type of heart failure, which response option MUST always be included in a compliant multiple-choice query?

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

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

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

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 139: Under KDIGO staging, a patient whose urine output drops to 0.3 mL/kg/hr for 20 consecutive hours would be classified as which AKI stage?

AKI Stage 1
AKI Stage 2
AKI Stage 3 (Correct answer)
Chronic kidney disease exacerbation

Correct answer: AKI Stage 3

KDIGO Stage 3 AKI includes urine output less than 0.3 mL/kg/hr for ≥12 hours or anuria for ≥12 hours.

Question 140: Under the Uniform Hospital Discharge Data Set (UHDDS) guidelines, when should AKI be coded as a secondary diagnosis?

When it affects patient care, requires clinical evaluation, or prolongs the length of stay (Correct answer)
When the physician lists it in the problem list but not the discharge summary
Only when dialysis is performed during the encounter
Only when it is the primary reason for admission

Correct answer: When it affects patient care, requires clinical evaluation, or prolongs the length of stay

UHDDS defines additional diagnoses as conditions that affect patient care in terms of requiring clinical evaluation, therapeutic treatment, diagnostic procedures, extended length of stay, or increased nursing care and monitoring.

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%

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