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| Section | Weight | Objectives |
|---|---|---|
| Topic 1: Risk Adjustment Models and Documentation Impact | 25% | - CMS-HCC model fundamentals and RAF scoring - Medicare Advantage payment structure and documentation requirements - RADV audit concepts and documentation compliance - Hierarchies, disease interactions, and compliant HCC reporting |
| Topic 2: Healthcare Regulations, Reimbursement, and Documentation Requirements | 35% | - Alternative payment models: ACO, MSSP, MACRA/MIPS - Provider coding and billing: CPT, Evaluation and Management (E/M), Medicare Physician Fee Schedule - Outpatient Prospective Payment System (OPPS) and Ambulatory Payment Classifications (APCs) - Official Guidelines for Coding and Reporting (OCG) for ICD-10-CM
|
| Topic 3: 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 4: CDI Program Concepts, Queries, and Quality | 20% | - Problem list maintenance, provider education, and program operations - 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 |
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NEW QUESTION # 86
PCP notes describe the presence of atrial fibrillation for 10 days. Atenolol, sotalol and rivaroxaban are ordered. Possible ablation is discussed. Identify the type of atrial fibrillation described in this clinical scenario.
Answer: B
Explanation:
Atrial fibrillation (AF) type is determined largely by episode duration and whether the rhythm self-terminates. In outpatient CDI education, paroxysmal AF is intermittent and typically terminates spontaneously, commonly within 7 days (often within 48 hours). Persistent AF is sustained and lasts more than 7 days, or requires active intervention (e.g., cardioversion) to restore sinus rhythm. This scenario documents AF "for 10 days," which exceeds the 7-day threshold and therefore best fits persistent AF. The management also aligns with a sustained arrhythmia strategy: rate control (atenolol), rhythm control/antiarrhythmic therapy (sotalol), stroke prevention anticoagulation (rivaroxaban), and discussion of catheter ablation, which is often considered for symptomatic or recurrent/persistent AF. "Chronic" is a nonspecific descriptor and not the preferred current classification term, and permanent AF implies a decision has been made not to pursue rhythm control (accepting AF long-term), which is not supported here because rhythm-control options are being considered.
NEW QUESTION # 87
Which entity is tasked by CMS to process both Part A and Part B beneficiary claims?
Answer: C
Explanation:
CMS assigns Medicare Administrative Contractors (MACs) to administer Medicare fee-for-service operations at the jurisdictional level, including processing and paying both Part A and Part B claims. In outpatient CDI terms, MACs are central because they apply Medicare coverage rules, edit logic, and payment policies that determine whether documentation supports medical necessity and correct coding for submitted claims. This includes adjudicating hospital outpatient (Part B) services and facility-based Part A services, handling provider enrollment functions, issuing Local Coverage Determinations (as applicable through their medical review processes), and responding to claim inquiries and appeals routing. By contrast, Recovery Audit Contractors (RACs) focus on identifying and recovering improper payments (post-payment auditing). Risk Adjustment Data Validation (RADV) contractors validate diagnosis data submitted for risk-adjusted programs (primarily Medicare Advantage), not routine FFS claim processing. Zone Program Integrity Contractors (ZPICs) (and their successors in some contexts) focus on program integrity and fraud/waste/abuse investigations rather than standard claim adjudication. Therefore, the entity responsible for processing Part A and Part B beneficiary claims is the MAC.
NEW QUESTION # 88
Using the table above, which of the following HCC(s) should be assigned for documentation stating the patient has resolving AKI due to ATN, creatinine levels slowly returning to baseline, and CKD- stage 3-4?
Answer: C
Explanation:
In HCC risk adjustment, chronic kidney disease (CKD) is captured by stage-based HCCs that are hierarchical-only the highest supported CKD stage in the hierarchy is counted for RAF when multiple stages (or a range) are referenced. The documentation includes "CKD - stage 3-4," which indicates the patient's baseline CKD severity falls somewhere between stage 3 and stage 4. When selecting from the provided table, stage 4 maps to HCC 327 and is higher than stage 3 categories (HCC 328 for stage 3B and HCC 329 for stage 3 except 3B). AKI due to ATN describes an acute process and does not replace the need to capture baseline CKD stage when it is clinically relevant and documented. Outpatient CDI best practice would be to query the provider to specify the exact CKD stage (since "3-4" is imprecise), but when forced to choose from the hierarchy shown, the correct HCC assignment based on the highest stated stage in the documented range is HCC 327 (CKD stage 4).
NEW QUESTION # 89
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 # 90
CMS-HCCs are used to
Answer: A
Explanation:
The CMS-HCC model is a risk adjustment methodology used primarily to set capitated payments for Medicare Advantage (MA) organizations based on the expected cost of caring for their enrolled beneficiaries. Under this approach, CMS calculates a Risk Adjustment Factor (RAF) for each member using demographic variables (such as age/sex and certain entitlement factors) plus disease burden captured from ICD-10-CM diagnoses that map to Hierarchical Condition Categories (HCCs). The resulting RAF increases or decreases the plan's payment to better match predicted healthcare needs-higher RAF for sicker, more complex patients and lower RAF for healthier patients. ACDIS outpatient CDI education emphasizes that the purpose is not physician reimbursement based on a "principal diagnosis" (an inpatient concept) and not payment distribution tied directly to quality performance (that aligns more with MIPS/VBP frameworks). It also does not adjust capitation payments specifically "to physicians," nor does it exclude advanced practice providers in the way described. The correct use is to determine MA plan capitation payments through risk-adjusted member-level projections.
NEW QUESTION # 91
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