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| Section | Weight | Objectives |
|---|---|---|
| Topic 1: Clinical Conditions, Pathophysiology, and Chart Review | 20% | - Clinical indicators, diagnostic tests, medications, and documentation triggers - Differentiating acute vs chronic, active vs historical conditions - Disease processes across all body systems and documentation relevance |
| Topic 2: Healthcare Regulations, Reimbursement, and Documentation Requirements | 35% | - Alternative payment models: ACO, MSSP, MACRA/MIPS - Official Guidelines for Coding and Reporting (OCG) for ICD-10-CM
- Provider coding and billing: CPT, Evaluation and Management (E/M), Medicare Physician Fee Schedule |
| Topic 3: CDI Program Concepts, Queries, and Quality | 20% | - Compliant query development: principles, structure, and non-leading language - CDI metrics: query rates, capture rates, quality scores, denial prevention - Regulatory compliance: HIPAA, OIG work plan, confidentiality - Problem list maintenance, provider education, and program operations |
| Topic 4: Risk Adjustment Models and Documentation Impact | 25% | - RADV audit concepts and documentation compliance - Medicare Advantage payment structure and documentation requirements - CMS-HCC model fundamentals and RAF scoring - Hierarchies, disease interactions, and compliant HCC reporting |
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NEW QUESTION # 102
What diagnoses are included in code category N18, chronic kidney disease?
Answer: D
Explanation:
ICD-10-CM category N18 (Chronic kidney disease) is used to report CKD by stage, including stage-based descriptors and end stage renal disease (ESRD). Within N18, codes identify CKD stage 1 through stage 5, ESRD (stage 5D), and CKD unspecified. Outpatient CDI review focuses on ensuring providers document the stage (often supported by eGFR trends) because stage drives correct code selection and accurately reflects disease severity for risk, quality, and medical necessity. Options that include dialysis are not part of N18 itself; dialysis status and encounter codes are reported elsewhere (e.g., dialysis dependence/status codes), not as N18 category diagnoses. AKI (acute kidney injury) and ATN (acute tubular necrosis) are acute renal conditions and are coded outside N18. Likewise, polycystic kidney disease and "uremia" are separate diagnoses with their own code categories. Therefore, the set that correctly matches what N18 represents is CKD stage-based diagnoses such as CKD stage 3, more advanced/severe CKD stages, and ESRD.
NEW QUESTION # 103
Which of the following concepts BEST reflects how risk adjustment is related to cost efficiency metrics?
Answer: D
Explanation:
Risk adjustment is used to make cost and efficiency comparisons fair by accounting for differences in patient severity and expected resource needs. In outpatient CDI, accurate documentation and coding of chronic and acute conditions (especially risk-adjusting diagnoses such as HCC-relevant conditions) directly influence the risk profile assigned to a patient population. That risk profile is then applied when evaluating utilization and cost measures-such as total cost of care, inpatient admissions, ED use, and other resource consumption-so that providers or groups caring for more complex patients are not inappropriately labeled as inefficient simply because their patients require more services. This aligns with option B: risk adjustment is applied to resource utilization measures. Option A is incorrect because E&M levels are a professional billing construct and are not the basis for risk score calculation. Option C is incorrect because physician time may affect E&M selection under certain rules, but it is not the mechanism for risk adjustment in cost efficiency analytics. Option D is incorrect because procedures/interventions describe services rendered, not the adjustment methodology itself.
NEW QUESTION # 104
A CDI specialist is writing a query and including information from another facility's EHR via shared notes. Understanding that the ability to view shared notes may be revoked by the patient at any time, and to ensure HIPAA guidelines are followed, which of the following elements are BEST to include when sending the query?
Answer: A
Explanation:
When a CDI query references information from an externally shared note, best practice is to include enough identifying detail so the provider can locate and validate the source even if access is later revoked or if the shared record becomes unavailable. From an outpatient CDI and HIPAA-aligned workflow perspective, the query should clearly cite: where the information came from (the location of the shared note within the EHR/external record set), who authored it (provider name), when it was created (date of shared note), and the specific clinical documentation being referenced (the relevant statement/findings). This supports transparency, auditability, and minimizes the risk of misattribution or relying on inaccessible information. Options B-D are missing one or more critical elements-most notably the date and/or location of the shared note-making it harder to verify the source. Including "follow-up procedure" is not the priority for HIPAA-compliant source identification; the key need is traceability of the external documentation used to support the clarification request.
NEW QUESTION # 105
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: C
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 # 106
Which diagnosis and treatment plan may generate a query?
Answer: D
Explanation:
Outpatient CDI queries are most commonly triggered when there is a disconnect between the documented diagnosis and the documented treatment plan, suggesting that the clinician may be managing an additional condition that is not clearly stated, or that the diagnosis is inaccurately documented. Options A and B reflect typical, clinically aligned management: luteinizing hormone-releasing hormone therapy is a standard treatment pathway for prostate carcinoma, and amiodarone is a recognized antiarrhythmic used in atrial fibrillation management in appropriate circumstances. Option C can also be clinically consistent because parenteral nutrition is often used when malnutrition is present and the patient cannot meet nutritional needs enterally. Option D is the outlier: "immunotherapy" is not a standard treatment for severe major depressive disorder and more commonly aligns with oncology or certain immune-mediated diseases. This mismatch would appropriately prompt a query to clarify the actual condition being treated (e.g., an active malignancy) or to confirm whether "immunotherapy" refers to something else (such as allergy immunotherapy) and whether depression is the correct, visit-relevant diagnosis being addressed.
NEW QUESTION # 107
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