ACDIS Updated CCDS Exam Questions and Answers by luis

Pressure-ulcer staging is one of the recognized circumstances in which ICD-10-CM permits the relevant clinical detail to be obtained from documentation by an appropriate non-provider clinician, such as a qualified wound-care nurse.

The provider establishes the medical diagnosis, while the wound-care clinician's specialized assessment may support the stage assignment. This distinction allows coding to reflect the expertise of clinicians who directly assess the wound without requiring physicians to duplicate every technical staging statement.

Option C is too broad. The exception permitting stage documentation from another clinician does not grant non-provider documentation unrestricted authority to establish all reportable medical diagnoses.

Pressure-ulcer stage is highly relevant because ICD-10-CM pressure-ulcer codes incorporate both anatomical site and stage. It can also have substantial implications for severity reporting, POA assessment, CMS HAC policy, nursing care, quality review, and risk adjustment.

When different clinicians document conflicting stages, clarification should be pursued rather than selecting the most severe value.

CCDS candidates should understand the distinction between provider-established diagnoses and specific coding elements that ICD-10-CM permits to originate from other qualified professionals.

CCDS Reference Topics: Pressure ulcers; wound staging; non-provider documentation; coding exceptions.

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A clinical validation query is appropriate because the documented diagnosis appears inconsistent with the available clinical evidence. The creatinine values remain essentially unchanged, urine output is normal, and there is no apparent treatment or monitoring consistent with acute renal dysfunction.

The CDI specialist cannot simply delete the diagnosis because providers are responsible for establishing diagnoses. Conversely, a diagnosis should not automatically be accepted when substantial clinical evidence raises a legitimate question about its validity.

A compliant query would present the documented AKI together with the pertinent renal findings and request clarification. The provider could confirm AKI and provide supporting clinical reasoning, revise the diagnosis, state that it was ruled out, or document another condition.

Assigning chronic kidney disease would be equally inappropriate because CKD requires evidence of chronic kidney abnormality and cannot be inferred from these laboratory values.

The August 2026 ACDIS/AHIMA query guidance supersedes prior versions and remains the foundational standard for clinical validation and documentation clarification.

Clinical validation protects data integrity because diagnoses influence reimbursement, quality reporting, severity measurement, utilization analysis, and downstream patient information.

CCDS Reference Topics: Clinical validation; AKI; unsupported diagnoses; provider clarification; compliance.

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CMS PSI 90, the Patient Safety and Adverse Events Composite, is one of the six measures used in the FY 2026 HAC Reduction Program.

CMS states that the program uses one claims-based patient-safety composite—PSI 90—plus five healthcare-associated infection measures: CLABSI, CAUTI, colon and abdominal hysterectomy surgical-site infection, MRSA bacteremia, and C. difficile infection.

Case mix index is an MS-DRG resource-intensity statistic and is not a HACRP quality measure. Query-response rate is an internal CDI performance metric. Patient-experience measures belong to other CMS quality frameworks, including Hospital VBP, rather than constituting a HACRP measure.

For FY 2026, hospitals with Total HAC Scores above the 75th percentile—effectively the worst-performing quartile—are subject to a 1% payment reduction under the program.

A CDI specialist should also distinguish HACRP from the separate HAC/POA payment provision. CMS explicitly identifies them as distinct programs, even though both involve hospital-acquired conditions.

CCDS Reference Topics: HACRP; PSI 90; healthcare-associated infections; patient safety; quality reimbursement.

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The clinical findings strongly support clarification of hyponatremia. A serum sodium concentration of 119 mEq/L represents substantial reduction below the usual reference range, and neurologic manifestations such as confusion are consistent with clinically significant hyponatremia. Administration of hypertonic saline and frequent sodium monitoring further demonstrate that the electrolyte abnormality is clinically important.

The CDI specialist should not independently assign the diagnosis based solely on the laboratory result. Instead, the abnormal sodium level, neurologic symptoms, and targeted therapy provide an appropriate clinical basis for a neutral provider query.

Hypernatremia represents elevated serum sodium and therefore contradicts the laboratory finding. Hyperkalemia relates to potassium rather than sodium. Metabolic alkalosis is an acid-base disturbance requiring supporting blood-gas and chemistry findings and is not established by the information provided.

Further specificity may also matter. Depending on the clinical record, the physician may determine that the hyponatremia is related to SIADH, volume depletion, medication use, heart failure, cirrhosis, or another etiology.

The CCDS role is to recognize the clinical significance of laboratory abnormalities and obtain clinically meaningful provider documentation rather than simply translating abnormal values into diagnoses.

CCDS Reference Topics: Electrolyte abnormalities; hyponatremia; laboratory interpretation; clinical indicators; documentation clarification.

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