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NEW QUESTION # 28
A CDI specialist identifies an opportunity to clarify a patient's BMI. The CDI specialist leaves a query within the medical record for the ancillary support team to address during the patient's visit. Which of the following BEST describes this type of query?
Answer: A
Explanation:
This scenario describes a query placed before the patient is seen, with the intent that the issue be addressed during the upcoming visit. In outpatient CDI practice, that is the defining feature of a prospective query: it is initiated ahead of the encounter so the provider and/or clinic team can capture needed specificity in real time (here, clarifying BMI-related documentation to support an obesity diagnosis when clinically appropriate). By contrast, a concurrent query is typically issued while the encounter is actively occurring or immediately as documentation is being created and reviewed in near-real time. A retrospective query occurs after the visit is completed, usually during post-encounter review, when opportunities are identified after documentation is finalized. "Prebill" refers to a workflow timing concept tied to billing hold/review before claim submission, not the clinical timing of when the patient will be seen. Because the query is placed in advance specifically to be addressed during the scheduled visit, prospective is the best classification.
NEW QUESTION # 29
An African American male enrolled in Medicaid has not been taking his blood pressure medication. Which of the following factors impacts this beneficiary's risk score?
Answer: A
Explanation:
Medicaid risk adjustment models generally calculate risk using two major categories of inputs: demographics and diagnosis data. Demographic factors commonly include gender and indicators tied to Medicaid status/eligibility (for example, eligibility category, dual status, disability-related eligibility, or other program qualifiers depending on the state/model). These demographic elements adjust expected cost and are foundational to the risk score even before considering diagnoses. By contrast, race is not a standard input for calculating Medicaid risk scores in typical risk adjustment methodologies, so options that include race are not supported. Likewise, "patient noncompliance" is primarily a clinical and quality-of-care issue and may affect treatment outcomes, but it is not itself a standard risk-score driver unless it is documented as a reportable, supported diagnosis that the specific model recognizes (and most models don't directly risk-adjust for nonadherence codes). Therefore, among the options given, Medicaid status and gender are the most clearly valid factors that impact the beneficiary's risk score.
NEW QUESTION # 30
A patient is seen in the obstetrical clinic, 6 weeks postpartum. She presents with resting heart rate of 58 BPM, initial blood pressure of 154/90, and respiratory rate of 20. She also complains of slight headaches, denies visual changes, and has no evidence of peripheral edema. History is significant for smoking and obesity. A blood pressure reading of 160/88 is taken at the end of the visit. The provider documents hypertension. Which of the following query opportunities is MOST appropriate?
Answer: A
Explanation:
In obstetric and postpartum coding, the most important clarification is the type/timing of hypertension because ICD-10-CM has distinct categories for chronic (pre-existing) hypertension, gestational hypertension, and hypertensive disorders that persist into or present during the postpartum period. At 6 weeks postpartum with elevated readings (including a systolic of 160) and headache, the documentation "hypertension" is not specific enough to determine whether this represents chronic hypertension that predates pregnancy, gestational hypertension that has not resolved, or another pregnancy-related hypertensive disorder requiring different obstetric coding and follow-up. ACDIS outpatient CDI guidance prioritizes queries that resolve coding-impactful ambiguity using clinically supported options without leading the provider. While postpartum preeclampsia could be a clinical consideration, the note does not provide key supporting elements (e.g., proteinuria or other definitive severe-feature criteria), so jumping directly to preeclampsia/eclampsia is less appropriate than clarifying onset and relationship to pregnancy. Linking hypertension to smoking is not a standard required linkage for diagnosis coding, and "hypertensive crisis" is not supported by the documentation provided.
NEW QUESTION # 31
A CDI specialist manager is reviewing the productivity metrics of the outpatient team and notes that one of the CDI specialists has a high query rate and a good physician response, but a low physician agree rate compared to the rest of the team. This likely indicates which of the following?
Answer: B
Explanation:
A high query rate with a strong physician response rate shows the CDI specialist is generating many queries and providers are opening/responding to them. However, a consistently low agree rate indicates providers frequently select "disagree," "clinically undetermined," or otherwise do not validate the query's suggested clarification. In outpatient CDI program management, that pattern most often reflects query quality problems-for example, queries that are not well-supported by encounter-specific clinical indicators, queries that are vague or overly speculative, or queries that do not align with outpatient reportability standards (e.g., prompting for diagnoses not clearly monitored/evaluated/assessed/treated). While leading queries are a compliance concern, the more direct operational inference from "high volume + answered + not agreed with" is that the queries are not clinically compelling or are poorly constructed, resulting in frequent provider non-concurrence. Case complexity alone would not reliably drive low agree rates if the queries were appropriately targeted and evidence-based. Therefore, the most likely interpretation is poor-quality queries requiring coaching on clinical support, clarity, and compliant construction.
NEW QUESTION # 32
Which of the following statements is true regarding RADV reviews?
Answer: D
Explanation:
RADV (Risk Adjustment Data Validation) is an audit process used to validate that risk-adjusting diagnoses submitted for payment are supported by compliant medical record documentation. A foundational requirement is that the record is properly authenticated by an acceptable provider-meaning the documentation must be attributable to the treating clinician through a valid signature. In compliant documentation standards emphasized in outpatient CDI education, acceptable authentication may be a traditional hand-written signature or an electronic signature/attestation that meets organizational and regulatory policy. Option B is not correct because diagnoses do not have to appear only on a facesheet or "final diagnosis" list; they may be supported within the body of the note (assessment/plan, problem-based charting, or other authenticated sections) as long as they are clearly documented and clinically supported. Options A and D are not reliably true statements in a general RADV context because RADV focuses on diagnoses supported by appropriate provider documentation and acceptable encounter record criteria; "technician-assigned" diagnoses are not acceptable, and radiology documentation alone may not meet all validation expectations depending on the program's rules and encounter context.
NEW QUESTION # 33
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