CCDS Exam — Questions and Answers

Question 1: Which of the following query scenarios represents an INAPPROPRIATE use of a physician query?

Querying to clarify the clinical significance of an abnormal laboratory finding
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)

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

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

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

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

Question 3: Why is it important for CDI specialists to query for a specific type of acute kidney injury rather than accepting 'acute kidney failure, unspecified'?

Specific AKI types such as tubular necrosis are MCCs while unspecified AKI is only a CC (Correct answer)
Staging is only required for CKD documentation, not AKI
Stage-specific AKI codes have no impact on MS-DRG assignment
Unspecified AKI always defaults to MCC status under MS-DRG grouping

Correct answer: Specific AKI types such as tubular necrosis are MCCs while unspecified AKI is only a CC

N17.0 (tubular necrosis) is classified as an MCC while N17.9 (unspecified AKI) is only a CC, meaning specificity directly impacts MS-DRG weight and reimbursement.

Question 4: A CDI specialist reviews a case where a patient with known cancer is admitted with fever, hypotension, and positive blood cultures. The oncologist documents 'febrile neutropenia.' What additional query should be considered?

Query for severe sepsis only if the patient required ICU transfer
Query only for MRSA bacteremia since cancer patients are high risk
Do not query since febrile neutropenia is an adequate sepsis equivalent for coding purposes
Query for sepsis if SOFA criteria for organ dysfunction are met alongside the documented infection (Correct answer)

Correct answer: Query for sepsis if SOFA criteria for organ dysfunction are met alongside the documented infection

Febrile neutropenia is a clinical syndrome but not synonymous with sepsis in ICD-10-CM. If the patient meets Sepsis-3 criteria (documented infection plus organ dysfunction with a SOFA increase of 2 or more points), the CDI specialist should query the oncologist to clarify whether sepsis is present.

Question 5: A patient with CKD Stage 3 (baseline creatinine 1.8 mg/dL) presents with creatinine of 3.2 mg/dL. The physician documents 'CKD Stage 3 with acute exacerbation.' What is the best CDS action?

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

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

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

Question 6: Which CDI metric measures how often physicians respond to queries compared to total queries sent?

Query response rate (Correct answer)
Query rate
Query agreement rate
Physician compliance rate

Correct answer: Query response rate

Query response rate measures the percentage of queries to which physicians provide a clinical response, regardless of whether the response results in a documentation change.

Question 7: Under ICD-10-PCS, which root operation describes surgically cutting a body part without draining fluids or removing tissue?

Release
Division (Correct answer)
Excision
Drainage

Correct answer: Division

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

Question 8: In ICD-10-CM, the 'code first' instruction requires the coder to:

Assign the manifestation code before the etiology code
Assign only the code marked 'code first' and exclude the other
Use the 'code first' code as an additional diagnosis only
Assign the etiology code before the manifestation code (Correct answer)

Correct answer: Assign the etiology code before the manifestation code

The 'code first' instruction in ICD-10-CM indicates an etiology/manifestation coding convention where the etiology must be sequenced before the manifestation.

Question 9: A physician documents 'nutritional deficiency' without specifying type or severity. The CDS should:

Query the physician for specificity regarding type and severity of the nutritional deficiency (Correct answer)
Escalate to the compliance team before contacting the physician
Code protein-calorie malnutrition E46 since it is the most common form
Assign E63.9 (unspecified nutritional deficiency) and close the review

Correct answer: Query the physician for specificity regarding type and severity of the nutritional deficiency

Vague documentation like 'nutritional deficiency' lacks coding specificity; a query is required to capture the exact type and severity for accurate ICD-10-CM code assignment.

Question 10: 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:

Resection
Repair
Replacement (Correct answer)
Reposition

Correct answer: Replacement

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

Question 11: Which of the following conditions would most likely map to a high-value HCC category, making it a priority for CDI query?

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

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

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

Question 12: Which type of AKI etiology is most commonly associated with contrast-induced nephropathy?

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

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 13: 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?

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

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

It is sequenced as the principal diagnosis
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 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 15: What does the term "clinical data mining" refer to?

Organizing data for billing purposes
Collecting data from clinical trials
Extracting and analyzing data from patient records to identify trends and patterns (Correct answer)
Recording data from medical devices

Correct answer: Extracting and analyzing data from patient records to identify trends and patterns

Clinical data mining involves the systematic process of extracting meaningful insights, trends, and patterns from large volumes of patient records and other clinical data. This technique uses statistical analysis and machine learning algorithms to uncover hidden relationships that can inform clinical decision-making, identify risk factors, improve treatment protocols, and enhance patient outcomes.

Question 16: Which documented condition, if present alongside AKI, would most likely result in an MS-DRG upgrade reflecting greater patient resource intensity?

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

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

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

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

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

Question 18: Which of the following is considered a 'qualified provider' who may document diagnoses for ICD-10-CM coding purposes in the inpatient setting?

Pharmacist documenting in the medication reconciliation record
Registered nurse documenting in the nursing care plan
Attending physician or other qualified healthcare practitioner legally accountable for the patient's care (Correct answer)
Physical therapist documenting in the rehabilitation notes

Correct answer: Attending physician or other qualified healthcare practitioner legally accountable for the patient's care

Per ICD-10-CM guidelines, diagnoses must be documented by the attending physician or other qualified healthcare practitioners who are legally accountable for establishing diagnoses in the inpatient setting.

Question 19: According to KDIGO criteria, Stage 1 AKI is defined as an increase in serum creatinine of at least how much within 48 hours?

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

Correct answer: 0.3 mg/dL

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

Question 20: What is the CDI specialist's role in skin substitute graft documentation for wound care procedures?

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

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

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

Question 21: 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 physicians are using electronic order sets
Whether nursing documentation matches physician notes
Whether the hospital is billing for all procedures performed
Whether POA indicators are being assigned accurately for all secondary diagnoses (Correct answer)

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

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

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

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

Question 23: A CDI specialist wants to query about the specificity of a patient's anemia. Which query format is MOST compliant with AHIMA/ACDIS guidelines?

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

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

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

Question 24: A CDI specialist is reviewing a patient with a BMI of 42 and the physician documents 'obesity.' What additional documentation should the CDI specialist query for?

The patient's weight loss goals
Whether the patient has ever dieted
The patient's diet history
Morbid (severe) obesity or Class III obesity to reflect the clinical severity accurately (Correct answer)

Correct answer: Morbid (severe) obesity or Class III obesity to reflect the clinical severity accurately

A BMI of 40 or greater qualifies as morbid (severe) obesity, and querying for this specificity affects DRG assignment and severity of illness reporting.

Question 25: Which UHDDS data element is used to define the principal diagnosis?

The condition established after study to be chiefly responsible for the admission (Correct answer)
The diagnosis that generates the highest reimbursement
The diagnosis with the highest ICD-10-CM code specificity
The first diagnosis listed in the physician's H&P

Correct answer: The condition established after study to be chiefly responsible for the admission

The UHDDS defines the principal diagnosis as the condition established after study to be chiefly responsible for occasioning the patient's admission.

Question 26: A patient is admitted for total knee replacement (TKR) and is transferred to the ICU post-operatively for respiratory failure requiring mechanical ventilation for 96 or more hours and a tracheostomy. How does this change the DRG?

The case shifts to MDC 4 with the knee replacement as additional procedure
The case stays in the orthopedic surgical DRG with the respiratory failure added as an MCC
Mechanical ventilation duration has no impact on DRG assignment for surgical cases
The mechanical ventilation duration and tracheostomy may shift the case to a pre-MDC respiratory DRG (Correct answer)

Correct answer: The mechanical ventilation duration and tracheostomy may shift the case to a pre-MDC respiratory DRG

Mechanical ventilation for 96 or more hours combined with a tracheostomy triggers a pre-MDC DRG assignment. This pre-MDC classification overrides the orthopedic MDC assignment.

Question 27: Which laboratory finding is most consistent with pre-renal acute kidney injury?

Urine sodium greater than 40 mEq/L
Fractional excretion of sodium (FENa) greater than 2%
Urine specific gravity less than 1.010
BUN-to-creatinine ratio greater than 20:1 (Correct answer)

Correct answer: BUN-to-creatinine ratio greater than 20:1

A BUN-to-creatinine ratio >20:1 reflects intact tubular function with avid urea reabsorption, characteristic of pre-renal AKI where kidneys respond to reduced perfusion.

Question 28: 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?

Code acute renal failure based on the creatinine values alone
Query the physician to clarify if this meets criteria for acute kidney injury (Correct answer)
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 29: A CDI specialist documents in the query that clarifying a diagnosis to 'acute kidney injury' will increase reimbursement by $4,000. This practice is:

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

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 30: Which of the following best describes the CDI impact of documenting 'acute systolic heart failure' versus 'acute heart failure, unspecified'?

Both terms map to the same ICD-10-CM code and DRG
Systolic specification increases diagnosis-related group (DRG) weight and reflects higher severity of illness (Correct answer)
Systolic heart failure only applies to EF below 40% and does not affect DRG
Unspecified heart failure captures higher complexity than systolic heart failure

Correct answer: Systolic specification increases diagnosis-related group (DRG) weight and reflects higher severity of illness

Specifying systolic versus diastolic heart failure maps to distinct ICD-10-CM codes that affect DRG assignment and quality metrics.

Question 31: What is a critical requirement for documenting a verbal query?

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

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

State vital statistics records
ACDIS CDI industry survey benchmarks (Correct answer)
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 33: 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 hospital's payer mix likely skews toward more complex patients
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 CDI program is performing at peak efficiency

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

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

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

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

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

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

Question 36: Why is a CDI query regarding present-on-admission (POA) status especially critical for pressure injuries?

POA queries are routine for all diagnoses and carry no special significance for pressure injuries
POA status affects only the length of stay calculation
Ambiguous POA status for pressure injuries can result in HAC designation, affecting reimbursement and quality scores (Correct answer)
POA status for pressure injuries is automatically determined by admission nursing notes

Correct answer: Ambiguous POA status for pressure injuries can result in HAC designation, affecting reimbursement and quality scores

Hospital-acquired Stage 3 and Stage 4 pressure injuries are CMS-designated HACs, meaning ambiguous POA documentation can trigger financial penalties and quality metric impacts.

Question 37: The Anti-Kickback Statute (AKS) is most directly relevant to CDI practice when:

A hospital offers financial incentives to physicians contingent on their documenting specific higher-weighted diagnoses (Correct answer)
A patient disputes a hospital bill and requests an itemized statement
A coder assigns an incorrect principal diagnosis without physician query
A CDI specialist sends a compliant open-ended query to a physician about a missing secondary diagnosis

Correct answer: A hospital offers financial incentives to physicians contingent on their documenting specific higher-weighted diagnoses

The AKS prohibits offering, paying, soliciting, or receiving anything of value to induce referrals or services covered by federal healthcare programs. Paying physicians bonuses tied to documenting diagnoses that increase reimbursement can be construed as a remuneration scheme that violates the AKS.

Question 38: Which of the following is a Hospital-Acquired Condition (HAC) that directly affects Medicare payment if not documented as present on admission?

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

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

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

Question 39: A CDI specialist is reviewing a medical record that contains a 'copy-forward' note where the attending copied the previous day's assessment unchanged for three consecutive days. What is the primary concern?

Copy-forward notes are prohibited by CMS and must be immediately reported to compliance
The attending will be penalized for duplicate documentation under Medicare billing rules
The notes may not accurately reflect the patient's current clinical status, risking documentation inaccuracy (Correct answer)
Copy-forward notes automatically void the authentication of subsequent notes

Correct answer: The notes may not accurately reflect the patient's current clinical status, risking documentation inaccuracy

Copy-forward or cloned notes that replicate previous documentation without reflecting the patient's current status create a documentation integrity risk. They may not accurately capture clinical changes.

Question 40: 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?

N
U (Correct answer)
W
Y

Correct answer: U

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

Question 41: The Hospital-Acquired Condition Reduction Program (HACRP) penalizes hospitals in which quartile for HAC performance?

All hospitals with any HAC occurrence regardless of quartile
Middle two quartiles (hospitals between the 25th and 75th percentile)
Top quartile (best-performing 25% of hospitals)
Bottom quartile (worst-performing 25% of hospitals) (Correct answer)

Correct answer: Bottom quartile (worst-performing 25% of hospitals)

The HACRP applies a 1% payment reduction to hospitals in the worst-performing quartile (bottom 25%) for total HAC scores.

Question 42: A patient admitted for pneumonia also undergoes diagnostic bronchoscopy with bronchoalveolar lavage. Which procedure is the principal procedure?

The procedure directly treating the principal diagnosis (none here, so bronchoscopy by default) (Correct answer)
There is no principal procedure when only a diagnostic procedure is done
Bronchoscopy with BAL only if it changes the final diagnosis
Bronchoscopy with BAL, because it is the only procedure performed

Correct answer: The procedure directly treating the principal diagnosis (none here, so bronchoscopy by default)

When no therapeutic procedure is performed, the diagnostic procedure most related to the principal diagnosis is designated the principal procedure.

Question 43: The quick SOFA (qSOFA) score includes which three clinical criteria?

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

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

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

Question 44: A patient undergoes cardiac catheterization revealing 70% LAD stenosis. The cardiologist documents 'significant CAD.' What should the CDI specialist consider?

Code coronary artery stenosis as the principal diagnosis
Query to determine if the CAD involves native versus bypass graft vessels and the number of vessels (Correct answer)
Query for acute MI since the stenosis is over 50%
Accept 'significant CAD' and assign the unspecified CAD code

Correct answer: Query to determine if the CAD involves native versus bypass graft vessels and the number of vessels

ICD-10-CM codes for CAD differentiate by vessel type (native/graft), number of vessels, and presence of angina, requiring specificity beyond 'significant CAD.'

Question 45: Which of the following is TRUE regarding the POA indicator 'W' (clinically undeterminable)?

It is only used for HAC-designated conditions
It applies when the provider cannot clinically determine whether a condition was present at admission despite thorough review (Correct answer)
It must be assigned for all diagnoses in the obstetrics code range
It is used interchangeably with 'U' when documentation is missing

Correct answer: It applies when the provider cannot clinically determine whether a condition was present at admission despite thorough review

The 'W' indicator is used when the clinical provider determines that it is not possible to clinically determine whether the condition was present at the time of admission, despite thorough clinical review.

Question 46: A patient is admitted with chest pain and subsequently diagnosed with NSTEMI. How should the documentation reflect the principal diagnosis?

Unstable angina, as the default cardiac admission diagnosis
Chest pain, since it was the presenting complaint
NSTEMI, as the condition established after study (Correct answer)
Both chest pain and NSTEMI as co-principal diagnoses

Correct answer: NSTEMI, as the condition established after study

Once the definitive diagnosis of NSTEMI is established after study, it replaces the presenting symptom (chest pain) as the principal diagnosis per UHDDS guidelines.

Question 47: A query asks a physician: 'Based on the elevated creatinine, BUN, and oliguria, does the patient have acute kidney injury?' This is an example of a:

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

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

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

Question 48: When evaluating the effectiveness of physician education sessions, which metric is the BEST indicator of sustained improvement?

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

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 49: A patient with decompensated cirrhosis presents with asterixis, confusion, and elevated ammonia. The physician's note reads 'mental status changes secondary to liver failure.' What is the most specific and clinically accurate query to initiate?

No query needed; the documentation is clinically sufficient
Query for toxic metabolic encephalopathy
Query for uremic encephalopathy
Query for hepatic encephalopathy (Correct answer)

Correct answer: Query for hepatic encephalopathy

Cirrhosis, asterixis, confusion, and elevated ammonia are the hallmark features of hepatic encephalopathy. While the physician's note references liver failure, it does not explicitly state the diagnosis. A query for hepatic encephalopathy yields a specific, clinically supported MCC rather than a generic symptom code.

Question 50: A patient with chronic systolic heart failure is admitted. The physician documents 'acute on chronic systolic heart failure' on day 2 but not in the discharge summary. What should the CDI specialist do?

Code the acute on chronic heart failure based on the day 2 note alone
Code only chronic systolic heart failure as documented in the discharge summary
Escalate to coding supervisor without querying
Issue a query asking the physician to clarify and confirm the acute exacerbation in the discharge summary (Correct answer)

Correct answer: Issue a query asking the physician to clarify and confirm the acute exacerbation in the discharge summary

All treating physician documentation can be used for coding, but a query ensures consistency and physician attestation in the final record.

Question 51: A CDI specialist reviews a case where a patient undergoes CABG using a saphenous vein graft harvested from the left leg. How many ICD-10-PCS codes are required at minimum?

Two codes: one for the bypass and one for the vein harvest (Correct answer)
One code with device character capturing the autologous venous graft
Three codes: bypass, vein harvest, and cardiopulmonary bypass
One code for the bypass only

Correct answer: Two codes: one for the bypass and one for the vein harvest

When a conduit is harvested from a different anatomical site than the bypass site, ICD-10-PCS requires a separate code for the harvest procedure. The CABG bypass code and the saphenous vein excision harvest code are both required.

Question 52: ICD-10-CM guideline Section I.C.19 covers coding for injuries. When multiple injuries are present, what guides principal diagnosis selection?

Always sequence the most severe injury as principal
Sequence the injury requiring the most surgical intervention as principal
The most serious injury, as determined by the provider, guides sequencing (Correct answer)
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 53: In the MS-DRG system, what is the significance of a 'Major Diagnostic Category' (MDC)?

It determines whether a case receives the CC or MCC version of the DRG
It is used to calculate the hospital's total CMI across all service lines
It determines the maximum number of secondary diagnoses allowed per claim
It groups cases by organ system or etiology and is the first-level classification before DRG assignment (Correct answer)

Correct answer: It groups cases by organ system or etiology and is the first-level classification before DRG assignment

Major Diagnostic Categories (MDCs) represent the first tier of DRG classification, grouping cases by primary organ system or disease etiology. The DRG grouper uses the MDC as the entry point before assigning a specific DRG.

Question 54: A CDI manager wants to benchmark their hospital's CMI against peer institutions. Which data source is MOST appropriate?

CMS Provider of Services file or Hospital Compare data (Correct answer)
The state health department's annual discharge report
The hospital's billing department quarterly revenue reports
The hospital's internal EHR analytics dashboard

Correct answer: CMS Provider of Services file or Hospital Compare data

CMS publicly reports CMI and other performance data through Hospital Compare and the Provider of Services file, enabling hospitals to benchmark themselves against peers of similar size, type, and geographic region.

Question 55: A CDI specialist reviews a case where sepsis is documented but no organ dysfunction is noted. How does this documentation gap affect quality metrics?

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

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

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

Question 56: Which of the following tools is commonly used for analyzing clinical documentation data?

Electronic Health Record (EHR) system
Database management systems
All of the above (Correct answer)
Spreadsheet software

Correct answer: All of the above

Analyzing clinical documentation data often requires a combination of tools to extract, process, and visualize information. Electronic Health Record (EHR) systems are the primary source of this data, while spreadsheet software is useful for basic analysis and visualization. Database management systems are crucial for handling large volumes of structured data, making 'All of the above' the correct choice as these tools collectively support comprehensive data analysis.

Question 57: When is a 'Yes/No' query format considered non-compliant?

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

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

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

Question 58: A hospital uses APR-DRG Risk of Mortality (ROM) subclasses primarily for which of the following purposes?

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

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

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

Question 59: A patient with end-stage renal disease (ESRD) on hemodialysis develops hyperkalemia. The CDIS should query whether which additional condition may be clinically supported?

Electrolyte and fluid balance disorder due to ESRD (Correct answer)
Fluid overload with associated pulmonary edema
Hypertensive CKD with heart failure
Acute kidney injury superimposed on CKD

Correct answer: Electrolyte and fluid balance disorder due to ESRD

Hyperkalemia in ESRD patients is a common complication of impaired renal electrolyte regulation and may support documentation of an electrolyte/fluid disorder for complete code capture.

Question 60: 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 original condition that required surgery
The surgical procedure performed at the other facility
The postoperative complication itself (Correct answer)
The reason the patient sought care at the current facility

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 61: Which documentation element is most critical for establishing medical necessity for an inpatient admission?

The number of diagnostic tests ordered
A clearly documented principal diagnosis with supporting clinical indicators (Correct answer)
The patient's insurance plan type
The attending physician's specialty

Correct answer: A clearly documented principal diagnosis with supporting clinical indicators

Medical necessity is established through a documented principal diagnosis supported by clinical indicators that justify the level of care provided.

Question 62: What is the primary goal of data analysis in clinical documentation?

To manage hospital inventory
To track employee performance
To monitor patient satisfaction
To ensure accurate coding and billing (Correct answer)

Correct answer: To ensure accurate coding and billing

The primary goal of data analysis in clinical documentation is to ensure the accuracy and completeness of patient records, which directly impacts coding and billing processes. Accurate documentation allows for correct assignment of diagnostic and procedural codes, leading to appropriate reimbursement for services rendered. It also supports compliance with regulatory requirements and provides reliable data for quality improvement initiatives.

Question 63: 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?

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

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 64: A patient is admitted from the emergency department with sepsis. The admission note does not mention acute kidney injury (AKI), but labs drawn in the ED show an elevated creatinine. AKI is first diagnosed on day 2. What is the likely POA status of the AKI?

Y (Yes) (Correct answer)
W (Clinically Undetermined)
U (Unknown)
N (No)

Correct answer: Y (Yes)

The POA indicator applies to conditions present at the time of the inpatient admission order. Since the clinical indicators (elevated creatinine) were present from the ED visit immediately preceding admission, the AKI was present on admission, even though it was not diagnosed until later. The correct POA is 'Y'.

Question 65: Which documentation standard requires that every medical record entry be dated, timed, and authenticated by the responsible provider?

CMS MS-DRG Definitions Manual
The Joint Commission (TJC) Medical Record Standards (Correct answer)
ICD-10-CM Official Coding Guidelines
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 66: A patient is admitted after a fall from a ladder at a construction site. The injury is a closed fracture of the femoral shaft. Which ICD-10-CM code captures the external cause of the initial encounter?

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

Correct answer: W11.XXXA

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

Question 67: Under ICD-10-CM, which code correctly captures severe protein-calorie malnutrition?

E41 – Nutritional marasmus (Correct answer)
E44.0 – Moderate protein-calorie malnutrition
Z72.4 – Inappropriate diet and eating habits
E46 – Unspecified protein-calorie malnutrition

Correct answer: E41 – Nutritional marasmus

E41 (Nutritional marasmus) represents severe protein-calorie malnutrition characterized by severe wasting without edema, distinct from kwashiorkor (E40) and mixed (E42).

Question 68: A patient receives IV contrast for CT imaging and develops a creatinine rise of 0.5 mg/dL (from 1.0 to 1.5 mg/dL) 48 hours later. The radiologist notes 'contrast nephropathy.' How should this be coded?

N14.11 as nephropathy induced by contrast media (Correct answer)
N17.9 with an adverse effect code for contrast media
Only code the underlying condition requiring the CT scan
T45.8X5A as the principal diagnosis

Correct answer: N14.11 as nephropathy induced by contrast media

N14.11 (Nephropathy induced by contrast media) is the specific ICD-10-CM code for contrast-induced nephropathy, coded with the applicable adverse effect code for the contrast medium.

Question 69: 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 70: When is it appropriate for a coder to assign the POA indicator 'U' (Unknown)?

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

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

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

Question 71: Which documentation element is most critical when a physician records 'cardiomegaly' on imaging but the clinical note mentions 'dilated cardiomyopathy'?

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

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 72: Which of the following documentation elements is REQUIRED by CMS Conditions of Participation for all inpatient medical records?

Daily physician progress notes co-signed by the attending
Nursing care plan updated every shift for the entire hospitalization
Authenticated history and physical completed within 24 hours of admission or prior to surgery (Correct answer)
Nutritional assessment completed within 24 hours of admission

Correct answer: Authenticated history and physical completed within 24 hours of admission or prior to surgery

CMS Conditions of Participation require that a history and physical examination be completed and authenticated within 24 hours of admission or before any surgery.

Question 73: A CDI specialist is training new staff on query language. Which of the following phrases is MOST appropriate to include in a compliant query?

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

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

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

Question 74: Which ICD-10-PCS approach value represents an endoscopic procedure performed entirely through an orifice without incision?

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

Correct answer: 8 – Via Natural or Artificial Opening Endoscopic

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

Question 75: 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 3 (Correct answer)
AKI Stage 2
AKI Stage 1
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 76: Which MS-DRG grouping concept refers to a secondary diagnosis that increases the severity of illness and resource use, elevating DRG assignment?

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

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

Correct answer: Data completeness

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

Question 78: Which quality metric directly measures the percentage of cases where a CDI query resulted in a documentation change?

Query response rate
Query compliance rate
Query agreement rate
Query impact rate (Correct answer)

Correct answer: Query impact rate

Query impact rate measures the proportion of queries that resulted in an actual change to clinical documentation, reflecting CDI program effectiveness.

Question 79: A CDI specialist is reviewing a bariatric surgery patient who presents 18 months post-operatively with documented inadequate protein intake and muscle wasting. What type of malnutrition is MOST likely?

Starvation-related malnutrition; document inadequate caloric intake only
Acute illness-related malnutrition; document acute inflammatory response
Non-illness-related malnutrition due to inadequate intake; document ASPEN criteria met (Correct answer)
Chronic illness-related malnutrition; document inflammatory markers

Correct answer: Non-illness-related malnutrition due to inadequate intake; document ASPEN criteria met

Post-bariatric malnutrition due to restricted intake and malabsorption is classified as non-illness-related malnutrition. Documentation should include ASPEN criteria including inadequate protein and energy intake plus evidence of weight loss, muscle wasting, or other criteria met.

Question 80: Under the False Claims Act, an employee who reports their employer's fraudulent billing practices to the federal government is legally called a:

Compliance arbitrator
Qui tam relator (Correct answer)
Documentation auditor
Concurrent reviewer

Correct answer: Qui tam relator

The FCA's qui tam provision allows a private individual (the relator) to file a lawsuit on behalf of the government and receive a portion of any recovery. CDI specialists who witness improper documentation practices that lead to false claims may have whistleblower standing under this provision.

Question 81: 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?

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
ICD-10-CM severe sepsis requires bacteremia; Sepsis-3 does not
Sepsis-3 eliminated the term 'severe sepsis'; ICD-10-CM retains it for coding purposes (Correct answer)

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

The pre-tracheostomy ventilator hours and post-tracheostomy hours are combined for duration coding (Correct answer)
Only hours after tracheostomy count toward ventilation duration
Tracheostomy eliminates the need for ventilation duration coding
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 83: 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
Y - Yes, present at time of admission
W - Clinically undeterminable

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

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

Question 84: A patient is readmitted 15 days after discharge for pneumonia with a new diagnosis of acute MI. How can CDI documentation impact the classification of this readmission under the Hospital Readmissions Reduction Program (HRRP)?

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

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

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

Question 85: A hospital's CDI program tracks 'query agreement rate.' A low agreement rate most likely indicates:

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

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 86: A CDI program wants to benchmark its Case Mix Index improvement. Which comparison would be MOST meaningful?

Comparing CMI to outpatient facility benchmarks
Comparing CMI to hospitals of all sizes nationally
Comparing CMI only to last year's internal data
Comparing CMI to peer hospitals with similar patient populations and bed counts (Correct answer)

Correct answer: Comparing CMI to peer hospitals with similar patient populations and bed counts

Benchmarking against peer hospitals with similar patient populations and size provides the most relevant comparison for assessing CMI performance and CDI program impact.

Question 87: A patient has a PaO2 of 58 mmHg on 4L nasal cannula and a respiratory rate of 28. The physician's assessment is 'hypoxia'. What type of query would be most appropriate?

A query asking to increase the patient's oxygen level.
A query presenting the clinical indicators and asking if a more specific diagnosis can be made. (Correct answer)
No query is needed as 'hypoxia' is a sufficient diagnosis.
A query asking the physician to document 'acute hypoxic respiratory failure'.

Correct answer: A query presenting the clinical indicators and asking if a more specific diagnosis can be made.

The clinical indicators (low PaO2 despite supplemental oxygen, tachypnea) are strongly suggestive of acute respiratory failure. The term 'hypoxia' is a symptom, not a definitive diagnosis. A query is needed to ask the physician if these clinical findings represent a more significant diagnosis like acute respiratory failure.

Question 88: A patient with documented stage III pressure ulcer on the coccyx at admission progresses to stage IV during the hospitalization. How should the POA and final pressure ulcer stage be coded?

Code stage III with POA=Y and do not code the progression
Code stage III with POA=Y and stage IV with POA=N as a separate diagnosis
Code stage IV with POA=Y since the ulcer was present at admission regardless of progression (Correct answer)
Code only stage IV with POA=N since that is the final documented stage

Correct answer: Code stage IV with POA=Y since the ulcer was present at admission regardless of progression

When a pressure ulcer is present on admission at a lower stage and worsens during the hospitalization, the highest stage documented during the stay is coded with POA=Y.

Question 89: Which key performance indicator (KPI) is often used to assess the quality of clinical documentation?

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

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

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

Correct answer: Principal diagnosis and other diagnoses

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

Question 91: Which strategy is commonly used to ensure that clinical documentation is accurate and reflects the patient's condition?

Minimizing documentation requirements
Reducing the length of patient stays
Increasing patient appointment frequency
Regular audits of clinical records (Correct answer)

Correct answer: Regular audits of clinical records

Regular audits of clinical records are a common and effective strategy to ensure that documentation is accurate and truly reflects the patient's condition. These audits involve systematically reviewing a sample of patient charts to identify areas of non-compliance, inconsistencies, or opportunities for improvement. By providing feedback and implementing corrective actions based on audit findings, healthcare organizations can continuously enhance the quality and completeness of their clinical documentation.

Question 92: Which action by a CDI specialist most likely constitutes 'query harassment' under professional guidelines?

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

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

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

Question 93: Which scenario represents an appropriate use of a verbal query according to AHIMA/ACDIS guidelines?

When the CDS prefers verbal communication over written forms
Routine clarification of a diagnosis that can wait until discharge
When the physician is known to ignore written queries
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 94: When is a verbal physician query considered acceptable under CDI compliance standards?

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

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

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

Question 95: The National Coverage Determinations (NCDs) issued by CMS are binding on which entities?

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

Correct answer: All Medicare contractors and providers nationwide

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

Question 96: 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 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
Queries are not permitted once a final bill has been submitted to the payer

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

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

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 98: A PEPPER report shows a hospital is a statistical outlier for 'one-day stays.' What does this indicate from a CDI compliance perspective?

PEPPER outlier status requires immediate self-disclosure to the OIG
The hospital may have admissions that do not meet inpatient criteria and should review medical necessity documentation (Correct answer)
One-day stays are a sign of appropriate CDI query activity
The hospital is efficiently discharging patients, reflecting strong care quality

Correct answer: The hospital may have admissions that do not meet inpatient criteria and should review medical necessity documentation

Statistical outlier status on PEPPER for one-day stays may indicate that patients are being admitted as inpatients when they should have been placed in observation status, suggesting possible medical necessity documentation issues.

Question 99: A CDI specialist notices that a physician's query response adds a new diagnosis that contradicts an earlier note in the same record. What should the CDI specialist do?

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

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

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

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

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

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 102: Under current CMS policy, which type of hospital is EXEMPT from the HAC payment adjustment?

Teaching hospitals with medical school affiliations
Urban hospitals with more than 500 beds
Hospitals participating in Medicare Advantage only
Critical Access Hospitals (CAHs) (Correct answer)

Correct answer: Critical Access Hospitals (CAHs)

Critical Access Hospitals (CAHs) are exempt from the HAC payment adjustment program because they are paid on a cost-based reimbursement methodology rather than the DRG system.

Question 103: Which organ dysfunction criterion under the full SOFA score would a CDI specialist cite when a septic patient has a serum creatinine of 2.8 mg/dL from a baseline of 0.9 mg/dL?

Renal dysfunction (elevated creatinine reflecting acute kidney injury) (Correct answer)
Cardiovascular dysfunction (vasopressor requirement)
Hepatic dysfunction (elevated bilirubin)
Hematologic dysfunction (thrombocytopenia)

Correct answer: Renal dysfunction (elevated creatinine reflecting acute kidney injury)

The SOFA score's renal component is assessed by serum creatinine level and urine output. A creatinine of 2.8 mg/dL from a baseline of 0.9 mg/dL represents a significant acute increase consistent with SOFA renal score of 3.

Question 104: A CDI specialist notices a patient with acute respiratory failure is on mechanical ventilation and the attending has not documented CLABSI despite positive blood cultures and a central line in place. What is the MOST appropriate action?

Add CLABSI to the diagnosis list based on the positive culture
Query the attending physician citing the positive blood culture, central line days, and fever documentation (Correct answer)
Do not query since CLABSI documentation would trigger a HAC payment reduction
Code bacteremia instead of CLABSI since physician documentation of CLABSI is absent

Correct answer: Query the attending physician citing the positive blood culture, central line days, and fever documentation

CDI specialists must query the physician with clinical indicators from the record (positive blood culture, fever, central line days) to confirm or deny CLABSI. Accuracy in coding is required regardless of financial impact.

Question 105: Under the HAC payment adjustment, which of the following conditions would trigger a payment reduction if NOT documented as present on admission?

Central line-associated bloodstream infection (CLABSI) (Correct answer)
Community-acquired pneumonia
Diabetic ketoacidosis
Congestive heart failure exacerbation

Correct answer: Central line-associated bloodstream infection (CLABSI)

CLABSI is one of CMS's designated HACs. When CLABSI develops during the hospitalization and is not documented as POA=Y, CMS will not pay the additional costs associated with treating that complication.

Question 106: When coding a patient who develops ventilator-associated pneumonia (VAP) during an ICU stay, which ICD-10-CM code is assigned?

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

Correct answer: J95.851 - Ventilator-associated pneumonia

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

Question 107: A query is sent to a physician asking: 'Do you agree the patient has sepsis?' This query is problematic primarily because it:

Should have been sent to the attending of record, not the treating physician
Does not include the patient's MRN in the query header
Uses the word 'agree,' which is not a recognized medical term
Is a leading yes/no query that suggests a specific diagnosis without balanced options (Correct answer)

Correct answer: Is a leading yes/no query that suggests a specific diagnosis without balanced options

Leading yes/no queries that suggest a specific answer are non-compliant because they bias the physician's response.

Question 108: A CDI specialist sends a query for hypertensive heart disease. The physician responds 'clinically undetermined.' What is the correct action?

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

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

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

Question 109: When a surgical wound dehisces postoperatively, what documentation is needed for accurate coding?

Documentation only as a wound requiring additional treatment
Documentation as a postoperative complication specifying the wound and depth of disruption (Correct answer)
Documentation as a new pressure injury since it occurred during hospitalization
Documentation as an unrelated skin condition separate from the surgical episode

Correct answer: Documentation as a postoperative complication specifying the wound and depth of disruption

Wound dehiscence following a procedure is coded as a postoperative complication, with documentation distinguishing superficial skin disruption from deeper fascial or organ-level separation.

Question 110: Which type of query is considered MOST efficient for obtaining a specific documentation clarification with multiple possible answers?

Multiple-choice query (Correct answer)
Verbal query with written follow-up
Open-ended query
Yes/no query

Correct answer: Multiple-choice query

Multiple-choice queries are the most efficient format for clarifications with several plausible diagnoses because they provide the physician with organized options based on clinical indicators.

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

Extraction
Excision
Extirpation (Correct answer)
Fragmentation

Correct answer: Extirpation

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

Question 112: Which clinical indicator would most support a CDI query for acute kidney injury in a hospitalized patient?

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

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

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

Question 113: Which documentation element is MOST critical for supporting a septic shock diagnosis for quality and reimbursement purposes?

Insertion of a central venous catheter
Administration of broad-spectrum antibiotics within 1 hour
Explicit physician attestation of septic shock in the final diagnosis (Correct answer)
Blood culture results positive for a pathogen

Correct answer: Explicit physician attestation of septic shock in the final diagnosis

For coding purposes, explicit physician documentation of 'septic shock' in the final diagnosis—not just treatment indicators—is required to assign the diagnosis.

Question 114: Which ICD-10-CM code category is used to report sepsis due to a gram-positive organism when the specific organism is identified?

A40 - Streptococcal sepsis
R65.2 - Severe sepsis
A41 - Other sepsis (Correct answer)
A02.1 - Salmonella septicemia

Correct answer: A41 - Other sepsis

Category A41 (Other sepsis) covers sepsis due to specific organisms including Staphylococcus aureus. The specific organism code from A40-A41 is sequenced first, followed by R65.2x if severe sepsis criteria are met.

Question 115: What is the primary goal of a CDI mortality review?

To communicate with the patient's family about the hospital stay.
To assign blame for any potential medical errors.
To ensure the final coded data accurately reflects the patient's severity of illness and risk of mortality. (Correct answer)
To determine the cause of death for the death certificate.

Correct answer: To ensure the final coded data accurately reflects the patient's severity of illness and risk of mortality.

The main purpose of a mortality review from a CDI perspective is to ensure the documentation fully captures all active conditions and their severity. This leads to accurate coding that reflects the patient's true severity of illness (SOI) and risk of mortality (ROM), which is crucial for risk-adjusted mortality metrics.

Question 116: What is the role of a Clinical Documentation Specialist (CDS) in a CDI program?

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

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

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

Question 117: When reviewing a medical record, which finding would most prompt a CDI specialist to initiate a query for a renal diagnosis?

Documentation of 'elevated creatinine' without any corresponding renal diagnosis (Correct answer)
A creatinine of 1.0 mg/dL in a patient with a known baseline of 0.95 mg/dL
Documentation of 'renal insufficiency' with creatinine trending downward to normal
Documentation of CKD Stage 2 with GFR confirmed at 65 mL/min

Correct answer: Documentation of 'elevated creatinine' without any corresponding renal diagnosis

When 'elevated creatinine' is documented without a corresponding coded renal diagnosis, CDI specialists have an opportunity to query for AKI or CKD if clinical criteria are met.

Question 118: Under the Cooperating Parties coding guidelines, which organization provides the official publication for ICD-10-CM/PCS coding advice?

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

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

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

Question 119: When calculating the Observed-to-Expected (O/E) mortality ratio, a ratio greater than 1.0 indicates:

The hospital's mortality is better than expected
Documentation is complete and accurate
The hospital's mortality is worse than expected (Correct answer)
The hospital has a higher CMI than the national average

Correct answer: The hospital's mortality is worse than expected

An O/E ratio above 1.0 means the hospital's actual observed mortality exceeded the risk-adjusted expected mortality, suggesting potential quality concerns.

Question 120: A patient is admitted with acute respiratory failure and pneumonia. The physician documents acute respiratory failure as the condition requiring the most intensive management. Per UHDDS and ICD-10-CM guidelines, what is the principal diagnosis?

Whichever condition the physician lists first in the H&P
Pneumonia, because it caused the respiratory failure
Acute respiratory failure, because it required the most resources (Correct answer)
Both conditions are co-principal and either may be sequenced first

Correct answer: Acute respiratory failure, because it required the most resources

When the attending physician identifies the condition requiring the most intensive management, that condition is selected as the principal diagnosis per UHDDS guidelines.

Question 121: 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?

Confront the physician in the hallway and demand an answer.
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)

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 122: What documentation is required for accurate wound debridement procedure coding in ICD-10-PCS?

The deepest tissue level debrided and the method used (excisional vs. non-excisional) (Correct answer)
The total number of debridement sessions performed during the stay
Only the wound dimensions before and after debridement
Only whether the debridement was performed in the operating room

Correct answer: The deepest tissue level debrided and the method used (excisional vs. non-excisional)

ICD-10-PCS debridement coding requires documentation of the deepest tissue level reached (skin, subcutaneous, muscle, or bone) and the method (excisional vs. non-excisional) to select the correct code.

Question 123: Which scenario represents an APPROPRIATE use of a retrospective query?

Querying after discharge solely to upgrade the DRG to improve hospital reimbursement
Querying after discharge when clinical indicators in the record suggest a condition that was never explicitly documented (Correct answer)
Querying to add a secondary diagnosis already captured and coded during the concurrent review
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 124: What is the primary risk of using 'leading' language in a physician query?

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

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 125: 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 126: What is the primary objective of healthcare documentation?

To reduce the time spent on patient care
To manage hospital staff assignments
To increase hospital revenue
To ensure accurate, complete, and timely documentation of patient care (Correct answer)

Correct answer: To ensure accurate, complete, and timely documentation of patient care

The primary objective of healthcare documentation is to ensure accurate, complete, and timely recording of all aspects of patient care. This includes the patient's medical history, diagnoses, treatments, medications, and responses to care. Comprehensive documentation is crucial for patient safety, continuity of care, legal protection, and accurate billing and reimbursement.

Question 127: 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 asking whether a secondary diagnosis existed before or at the time of inpatient admission (Correct answer)
A query to determine whether a condition requires treatment during the current hospitalization
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 128: From a CDI standpoint, why is specificity in HCC documentation critical for a Medicare Advantage population?

HCC specificity only matters for surgical cases, not medical admissions
Specific diagnoses capture true disease burden, affecting capitation payments and ensuring the plan receives adequate funding to manage the patient's care (Correct answer)
Specific diagnoses determine the patient's inpatient length of stay targets
HCC codes replace ICD-10-CM codes on the claim form for Medicare Advantage

Correct answer: Specific diagnoses capture true disease burden, affecting capitation payments and ensuring the plan receives adequate funding to manage the patient's care

Medicare Advantage plans receive risk-adjusted capitation payments from CMS based on the HCC profile of their enrollees. Under-documented diagnoses lead to lower risk scores, underpayment to the plan, and potentially inadequate resources for care management. Specificity directly links clinical accuracy to financial sustainability.

Question 129: A CDS program tracks 'initial query rate' as the number of queries issued divided by the number of records reviewed. This metric primarily measures:

Documentation opportunity identification (Correct answer)
Program efficiency
Physician compliance
Coder productivity

Correct answer: Documentation opportunity identification

The initial query rate reflects how often reviewers identify a documentation opportunity requiring clarification per record reviewed.

Question 130: Under the Surviving Sepsis Campaign 1-hour bundle, which action should be completed FIRST for a patient meeting sepsis criteria?

Measure lactate level (Correct answer)
Administer vasopressors
Obtain echocardiogram
Insert a urinary catheter for strict I&O

Correct answer: Measure lactate level

The 1-hour bundle begins with measuring lactate, which guides resuscitation targets and risk-stratifies the patient for septic shock.

Question 131: What is the financial impact to a hospital if a patient acquires a Stage 3 pressure ulcer (a HAC) during their stay?

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

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

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

Correct answer: Character 5 (Approach)

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

Question 133: A patient develops a catheter-associated urinary tract infection (CAUTI) on the third day of their hospital stay. What is the correct Present on Admission (POA) indicator for this diagnosis?

W (Clinically undetermined)
Y (Yes, present on admission)
N (No, not present on admission) (Correct answer)
U (Unknown, documentation insufficient)

Correct answer: N (No, not present on admission)

The POA indicator 'N' signifies that the condition was not present at the time of inpatient admission. Since the CAUTI developed after admission, 'N' is the correct indicator.

Question 134: Which of the following best explains the 'hierarchical' principle in the HCC model?

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

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

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

Question 135: 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 verbal query with no documentation in the medical record
A yes/no query asking 'Does this patient have sepsis?'
A multiple-choice query offering clinically appropriate diagnoses plus 'other' and 'clinically undetermined' (Correct answer)

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

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

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

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

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

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

Question 138: 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)
SOI and ROM scores are averaged to produce a single quality indicator
ROM is used only for surgical DRGs while SOI applies to medical DRGs

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 139: In the CMS-HCC model, a patient's chronic conditions must be re-documented each plan year to be included in the risk score. This requirement is best described as:

Annual recapture (Correct answer)
Hierarchical condition coding
Prospective documentation
Concurrent review

Correct answer: Annual recapture

Annual recapture means that HCCs do not carry forward automatically from prior years — each condition must be documented in the current measurement year for it to affect the risk score. This drives the CDI and coding focus on re-documenting chronic conditions at every relevant encounter.

Question 140: Which metric directly measures the financial impact of a CDS program on hospital reimbursement?

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

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.

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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