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NEW QUESTION # 107
A CDI specialist is following up on a query while the provider is seeing patients in the clinic. The BEST action that will support a quick and compliant response to the query is to
Answer: B
Explanation:
Outpatient CDI follow-up must balance responsiveness with confidentiality and professional standards. The most compliant approach is to communicate query-related information in a setting that protects protected health information and minimizes the risk of incidental disclosure. Discussing the query in a private room with the door closed supports timely clarification while maintaining privacy, avoiding conversations that could be overheard by patients, visitors, or staff who are not involved in the patient's care. Catching the provider in the hallway is faster but increases privacy risk because clinical details can be overheard, and it may also distract the provider in a high-traffic environment. Leaving a sticky note on the next patient's chart is inappropriate because it can be seen by others, may be misplaced, and can create compliance and medico-legal concerns (including mixing patients or leaving PHI unsecured). Waiting for the next scheduled meeting may be compliant but does not support a quick response, potentially delaying coding completion and data integrity. Therefore, a private discussion is both the quickest and most compliant option.
NEW QUESTION # 108
The majority of E/M services are based on which of the following criteria?
Answer: D
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 # 109
Which of the following is a form of a cardiac condition that may be treated with a beta-blocker?
Answer: B
Explanation:
Beta-blockers are commonly used in the management of coronary artery disease (CAD) because they lower heart rate, decrease myocardial contractility, and reduce oxygen demand-key goals in treating stable angina and in secondary prevention after myocardial infarction. In outpatient chart review, ACDIS-focused clinical documentation education emphasizes linking the medication to the condition being managed (e.g., "CAD with angina-on metoprolol for symptom control" or "history of MI-on beta-blocker for secondary prevention") to support accurate diagnosis reporting and demonstrate ongoing assessment and treatment. By contrast, third-degree (complete) heart block and sinus bradycardia are conditions where beta-blockers are typically avoided or used only with extreme caution because they can worsen conduction delay and slow the heart rate further. Cardiomyopathy can sometimes be treated with certain evidence-based beta-blockers when the clinical context is systolic heart failure, but the option most broadly and reliably associated with beta-blocker treatment in standard outpatient practice and documentation is CAD.
NEW QUESTION # 110
Based on previous documentation, which of the following diagnoses would a CDI specialist be MOST likely to bring to the provider's attention in preparation for an upcoming visit of a 70-year-old patient?
Answer: D
Explanation:
In outpatient CDI, "pre-visit" or prospective preparation focuses on chronic, clinically significant conditions that are likely to remain active and that should be reassessed and documented with clear MEAT support (monitor, evaluate, assess/address, treat) during the upcoming encounter. Epilepsy, chronic heart failure, and Crohn's disease are all long-term conditions that commonly require ongoing medication management, monitoring, and periodic reassessment, making them strong candidates for reminder/education to ensure the provider documents current status (controlled vs uncontrolled, exacerbation, complications, and treatment plan). This also supports accurate risk adjustment because chronic conditions with ongoing impact are the ones expected to be recaptured when addressed. In contrast, option C includes "family history," which is not a current active condition for risk adjustment, and options D includes acute/self-limited problems (syncope episode, pharyngitis) that are less appropriate as pre-visit chronic-condition prompts. Option B mixes chronic disease with items that may be historical or encounter-specific (compression fracture timing/status), making it less consistently targetable than option A.
NEW QUESTION # 111
A patient presents to the clinic with indwelling Foley catheter, symptoms of fatigue, and low back pain with BPH. Labs reveal WBC 20, and the urine culture is positive for E. coli. Prescription antibiotics are ordered for a UTI. Which of the following is the BEST query opportunity?
Answer: D
Explanation:
The strongest CDI query opportunity is clarifying whether the UTI is catheter-associated. The patient has an indwelling Foley catheter, significant leukocytosis (WBC 20), a positive urine culture for E. coli, and is being treated with antibiotics for UTI-these indicators raise a clear question about the etiology of infection and whether it is related to the urinary catheter. In outpatient CDI practice, linking the infection to a device (when clinically supported) improves documentation accuracy, supports correct code assignment, and has important quality and compliance implications because catheter-associated UTIs are captured differently than uncomplicated UTIs. By comparison, querying the "etiology of BPH" is not supported as an immediate gap (BPH is already stated), and the "etiology of low back pain" is less directly tied to the documented treatment focus (UTI management). "Leukocytosis" is a lab finding that is already objectively supported and often represents a symptom/abnormal result rather than the principal clarification needed. Therefore, confirming whether the UTI is related to the Foley catheter is the best, most clinically anchored query.
NEW QUESTION # 112
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