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| Section | Weight | Objectives |
|---|---|---|
| Topic 1: Clinical Conditions, Pathophysiology, and Chart Review | 20% | - Clinical indicators, diagnostic tests, medications, and documentation triggers - Disease processes across all body systems and documentation relevance - Differentiating acute vs chronic, active vs historical conditions |
| Topic 2: Healthcare Regulations, Reimbursement, and Documentation Requirements | 35% | - Provider coding and billing: CPT, Evaluation and Management (E/M), Medicare Physician Fee Schedule - Official Guidelines for Coding and Reporting (OCG) for ICD-10-CM
- Alternative payment models: ACO, MSSP, MACRA/MIPS |
| Topic 3: Risk Adjustment Models and Documentation Impact | 25% | - CMS-HCC model fundamentals and RAF scoring - RADV audit concepts and documentation compliance - Medicare Advantage payment structure and documentation requirements - Hierarchies, disease interactions, and compliant HCC reporting |
| Topic 4: CDI Program Concepts, Queries, and Quality | 20% | - Regulatory compliance: HIPAA, OIG work plan, confidentiality - CDI metrics: query rates, capture rates, quality scores, denial prevention - Problem list maintenance, provider education, and program operations - Compliant query development: principles, structure, and non-leading language |
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問題 #93
Which of the following is true of the RAF metric?
答案：D
解題說明：
RAF (Risk Adjustment Factor) is a population risk stratification metric used in risk adjustment models to estimate expected healthcare resource utilization for an individual beneficiary relative to an average patient. In outpatient CDI, RAF is driven by a combination of demographic elements (such as age/sex and eligibility/status factors) and-critically-documented, coded conditions that map to risk categories (e.g., HCCs). The intent is not to "predict the provider's reimbursement" for the current year in a direct, visit-by-visit sense; rather, RAF contributes to actuarial projections of expected cost and supports payment benchmarking and budget setting in value-based arrangements (e.g., Medicare Advantage and certain shared savings models). RAF is also not based only on demographics (eliminating option B) and it does not determine reimbursement for each individual office visit (eliminating option D). ACDIS outpatient CDI emphasizes that accurate, specific documentation and coding of active, clinically supported conditions improves the accuracy of RAF, which in turn better aligns projected costs and comparisons across attributed populations.
問題 #94
Along with history and examination, which of the following is considered a key component in reporting evaluation and management services?
答案：B
解題說明：
For reporting Evaluation and Management (E/M) services, the longstanding "key components" framework recognizes history, examination, and medical decision making (MDM) as the core elements used to determine the appropriate E/M level when the service is not reported based on time. In outpatient CDI education aligned with ACDIS concepts, MDM is emphasized because it reflects the clinician's cognitive work and risk-based thinking: the complexity of problems addressed, the amount/complexity of data reviewed and analyzed (labs, imaging, external notes, independent interpretation), and the risk of complications and/or morbidity from additional testing or treatment. "Review of systems" is a sub-element of the history component, not a separate key component. "Nature of presenting problem" and "coordination of care" can be clinically relevant and may support medical necessity or time-based billing (when documented appropriately), but they are not one of the three key components that define E/M reporting structure. Therefore, the best answer is Medical decision making.
問題 #95
A patient is seen at the clinic for a fever, and the provider documents possible Zika virus. A CDI specialist reviews the record and notes that a positive serology test indicates the Zika virus. Which of the following should the CDI specialist do NEXT?
答案：C
解題說明：
In the outpatient setting, diagnoses documented as uncertain (e.g., "possible," "probable," "suspected," "rule out") are generally not coded as confirmed conditions; instead, coding is based on confirmed diagnoses or, when not confirmed, the presenting signs/symptoms. Here, the provider documented only "possible Zika," which is not a confirmed diagnosis for outpatient reporting. Even though the CDI specialist sees a positive serology result, lab data alone does not replace provider diagnostic confirmation in the assessment/plan. The appropriate next step is to query the provider to confirm whether Zika is the established diagnosis based on the positive test (and whether it is clinically addressed during the encounter). If confirmed, Zika can be coded appropriately and sequenced based on the reason for the visit; if not confirmed or still under evaluation, the symptom (fever) remains first-listed. Option B is incorrect because coders do not "code the result" of a serology test as a diagnosis; they code the condition the test supports once clinically confirmed.
問題 #96
A patient presents to the PCP's office with LLE edema and pain for 3 days. The problem list indicates morbid obesity and a history of DVT. Vital signs are T 37.9, P 76, R 12, BP 142/88, BMI 46. Documentation states: "Patient presents with LLE edema, increased pain, and hx of DVT. Sedentary lifestyle and contraindications to anticoagulation therapy. LLE warm to touch, 3+ edema from ankle to knee. Pedal pulses 2+ on L and 3+ on R." Doppler exam indicates DVT. The PCP should be queried for which of the following diagnoses?
答案：D
解題說明：
The documented indicators strongly support two clarification needs that affect accurate outpatient reporting. First, morbid obesity is supported by an objective BMI of 46, and outpatient CDI practice emphasizes ensuring obesity class is clearly documented as a diagnosis (not only implied by BMI) and that it is clinically relevant to care planning and risk (e.g., contributes to thrombotic risk, impacts treatment options). Second, the Doppler "indicates DVT," but the record also notes a history of DVT, creating ambiguity about status-is this an acute new/recurrent DVT, a chronic/residual thrombosis, or a prior condition now re-identified? Clarifying acuity/status is essential because it changes code selection and clinical severity representation and supports medical necessity for management decisions, especially given "contraindications to anticoagulation." Hypertensive urgency is not supported (BP 142/88 without crisis features), and "hypercoagulability" is not established by the provided indicators. Therefore, querying for morbid obesity and DVT status is most appropriate.
問題 #97
Documentation from which of the following facility settings contributes to the CMS-HCC risk score?
答案：A
解題說明：
Under CMS-HCC risk adjustment (commonly applied to Medicare Advantage), qualifying diagnoses must come from acceptable encounter/claim sources and eligible provider types. Hospital-based outpatient services (including a hospital ambulatory clinic) are among the standard, acceptable settings where diagnoses documented, coded, and submitted on qualifying encounters may be used for risk adjustment-assuming they are supported, assessed/managed, and submitted per program requirements. In contrast, certain facility claim types do not typically contribute to CMS-HCC capture in the same way. Hospice care is generally treated as a carve-out/unique payment environment and is not relied upon as a routine source of risk-adjusting diagnosis capture for the member's ongoing RAF. Renal dialysis centers (ESRD facilities) likewise operate under specialized payment constructs and are not the typical outpatient setting used to drive CMS-HCC diagnosis capture for risk adjustment in standard CDI workflows. Freestanding ambulatory surgical centers also frequently fall outside the usual risk-adjustment-eligible encounter sources emphasized in outpatient CDI programs. Therefore, the hospital ambulatory clinic is the correct setting among these choices.
問題 #98
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