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| Section | Weight | Objectives |
|---|---|---|
| Topic 1: Clinical Conditions, Pathophysiology, and Chart Review | 20% | - Differentiating acute vs chronic, active vs historical conditions - Disease processes across all body systems and documentation relevance - Clinical indicators, diagnostic tests, medications, and documentation triggers |
| Topic 2: Risk Adjustment Models and Documentation Impact | 25% | - Medicare Advantage payment structure and documentation requirements - CMS-HCC model fundamentals and RAF scoring - RADV audit concepts and documentation compliance - Hierarchies, disease interactions, and compliant HCC reporting |
| Topic 3: Healthcare Regulations, Reimbursement, and Documentation Requirements | 35% | - Outpatient Prospective Payment System (OPPS) and Ambulatory Payment Classifications (APCs) - Provider coding and billing: CPT, Evaluation and Management (E/M), Medicare Physician Fee Schedule - Alternative payment models: ACO, MSSP, MACRA/MIPS - Official Guidelines for Coding and Reporting (OCG) for ICD-10-CM
|
| Topic 4: CDI Program Concepts, Queries, and Quality | 20% | - Problem list maintenance, provider education, and program operations - Regulatory compliance: HIPAA, OIG work plan, confidentiality - CDI metrics: query rates, capture rates, quality scores, denial prevention - Compliant query development: principles, structure, and non-leading language |
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NEW QUESTION # 26
Given the following CMS-HCC categories, which is the correct order (highest to lowest) in the hierarchy?
Answer: B
Explanation:
In the CMS-HCC model, certain disease groupings are arranged in hierarchies so that when multiple related conditions are reported for the same patient, only the most severe (highest-ranked) HCC in that hierarchy is counted for risk adjustment. This prevents "double counting" of clinically related conditions that represent the same underlying burden of illness. The cancer-related HCCs in the 35-38 range are an example of this hierarchical design: if a patient has diagnoses that map to more than one of these HCCs, the model retains the highest-ranked category and suppresses the lower ones. Therefore, the correct hierarchy order is from the most severe category (HCC 35) down sequentially through HCC 36, HCC 37, and HCC 38. From an outpatient CDI perspective, this reinforces why accuracy and specificity matter: documentation should clearly establish the most clinically severe, active, and treated condition so the correct (highest) HCC is captured, rather than relying on nonspecific or less severe descriptors that could under-represent patient complexity.
NEW QUESTION # 27
The majority of E/M services are based on which of the following criteria?
Answer: C
Explanation:
In outpatient CDI and coding education, selecting the correct E/M code starts with identifying the encounter category (e.g., office/outpatient vs inpatient/observation vs ED) and whether the patient is new or established, because these define the applicable CPT code range. Next, the level of service is selected within that range based on the documentation supporting the required elements for that code family. For most E/M services, "site of service" (place/setting) and "new vs established" are foundational code-selection drivers, while "level" is determined by the record's support for the applicable leveling methodology (commonly medical decision making and, when allowed/appropriate, time). Time can be a valid leveling method for many office/outpatient E/M visits, but it is not universally the basis for the majority of E/M services across all categories; it is an alternative pathway when documentation supports it. Physician specialty and patient age do not define the majority of E/M code selection. Therefore, the best overall statement is new/established status + site of service + level of service.
NEW QUESTION # 28
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 # 29
In which of the following situations would a yes/no query format be considered compliant?
Answer: A
Explanation:
A yes/no query format is considered compliant when it is used to resolve a clear documentation conflict and the provider is being asked to confirm which statement accurately reflects the patient's condition for that encounter. In these situations, the intent is not to introduce a new diagnosis or steer the provider toward a particular coded outcome, but to reconcile inconsistent information already present in the record (e.g., one clinician documents a condition and another documents the opposite, or different notes describe different statuses). A focused yes/no confirmation can be appropriate because the clinical question is essentially binary: which interpretation is correct. By contrast, obtaining a new diagnosis generally requires an open-ended or multiple-choice format with balanced options (including "unable to determine") and strong encounter-specific indicators to avoid leading. Likewise, organism specification and acuity clarification often involve more than two clinically valid possibilities (different organisms, acute vs chronic vs acute-on-chronic, etc.), making yes/no overly restrictive and potentially leading. Therefore, resolving conflicting documentation is the best fit for a compliant yes/no query.
NEW QUESTION # 30
A patient presents to the clinic for follow up of type 2 diabetes. The patient is also noted to have peripheral neuropathy. The patient has COPD and is found to have no recent exacerbations. The patient also has a history of depression, reported as stable. Which of the following CMS-HCCs will be captured for this visit?
HCC 17: Diabetes with Acute Complications
HCC 18: Diabetes with Chronic Complications
HCC 19: Diabetes without Complications
HCC 58: Major Depressive, Bipolar and Paranoid Disorders
HCC 111: Chronic Obstructive Pulmonary Disease
Answer: A
Explanation:
In the CMS-HCC model, diabetes categories are hierarchical, meaning you capture the highest supported diabetes HCC for the year, not multiple diabetes HCCs simultaneously. Type 2 diabetes with peripheral neuropathy represents a chronic diabetic complication, so it maps to HCC 18 (Diabetes with Chronic Complications) rather than HCC 19 (without complications) or HCC 17 (acute complications). COPD is documented as present and clinically relevant (even without an exacerbation) and therefore maps to HCC 111 (Chronic Obstructive Pulmonary Disease) when it is assessed/managed as part of the visit. "History of depression, stable" does not necessarily meet the threshold for HCC 58, which is reserved for specific serious psychiatric diagnoses (e.g., major depressive disorder, bipolar disorder, paranoid disorders). A general "depression" history, especially if not specified as major depressive disorder and not actively addressed, often will not support HCC 58 capture. Therefore, the visit captures HCC 18 and HCC 111 only.
NEW QUESTION # 31
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