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NEW QUESTION # 34
A patient is seen in the office for a persistent cough. Provider documentation states: "History of chronic obstructive pulmonary disease, asthma, and hypertension. Hypertension treated with Enalapril. Cough an adverse effect of the ACE inhibitor; discontinue Enalapril. COPD stable. Instructed to continue meds for COPD/asthma." Which of the following diagnoses should be reported for this encounter?
Answer: B
Explanation:
Outpatient diagnosis reporting requires coding conditions that are evaluated, assessed, treated, or that influence care/management at the encounter. The chief reason for the visit is the persistent cough, which is assessed and attributed to an adverse effect of an ACE inhibitor (enalapril). For outpatient coding of medication adverse effects, the documentation supports reporting both the manifestation (cough) and the adverse effect of the drug (ACE inhibitor adverse effect), because the provider identified the causal relationship and changed therapy by discontinuing enalapril. In addition, the provider addresses chronic conditions that are clinically relevant to the visit: COPD is assessed as "stable" and the patient is instructed to continue COPD/asthma medications, demonstrating ongoing management. Hypertension also remains relevant because medication therapy is adjusted due to the adverse effect; the patient still has HTN even though one agent is discontinued. Therefore, all five items-cough, ACE inhibitor adverse effect, COPD, asthma, and hypertension-are supported and should be reported, making option D the most appropriate.
NEW QUESTION # 35
Which of the following is a key component that is used to calculate Relative Value Units (RVUs)?
Answer: B
Explanation:
RVUs are the foundation of Medicare's physician fee schedule methodology and are built from three core components: physician work (wRVU), practice expense (peRVU), and malpractice (mpRVU). The malpractice expense RVU reflects the relative professional liability insurance cost associated with providing a service and is a defined element of the RVU calculation used to determine payment rates. In outpatient documentation and CDI education, it's important to distinguish what drives code selection versus what is a payment calculation ingredient. Time with the patient and medical decision making influence E/M code selection under current E/M rules, but they are not standalone components of the RVU formula itself-they contribute indirectly by determining which CPT code is billed, and each CPT code has preassigned RVUs. Physician specialty type also is not a direct RVU component, even though specialty patterns can affect typical service mix and overall wRVU productivity. Therefore, among the options, malpractice expense is the explicit RVU component used in the calculation.
NEW QUESTION # 36
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: B
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 # 37
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: D
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 # 38
A patient with stage 3 CKD presents to the clinic for evaluation. Upon review of labs, an elevated iPTH and a normal phosphorus level are noted. Which of the following diagnoses may be appropriately queried based upon these lab values?
Answer: D
Explanation:
In stage 3 chronic kidney disease, impaired vitamin D activation and early disturbances in calcium-phosphate regulation commonly drive a compensatory rise in parathyroid hormone (PTH), known as secondary hyperparathyroidism of renal origin. Outpatient CDI chart review looks for clinical indicators that suggest a condition being evaluated or requiring management, and an elevated iPTH in a CKD patient is a classic indicator that supports querying the provider for CKD-related mineral and bone disorder, specifically renal secondary hyperparathyroidism, if it is clinically being assessed/treated (e.g., monitoring trends, prescribing vitamin D analogs, calcimimetics, dietary counseling, nephrology follow-up). Primary hyperparathyroidism is less supported here because it typically requires a different biochemical pattern and clinical context (often hypercalcemia) rather than being driven by CKD physiology. Hypoparathyroidism is the opposite process (low PTH), making option C inconsistent with the lab finding. Option D is not supported because phosphorus is normal, not low, and hypophosphatemia is not documented as a driver. Therefore, querying for renal secondary hyperparathyroidism is most appropriate.
NEW QUESTION # 39
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