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>> Examinations CCDS-O Actual Questions <<
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NEW QUESTION # 132
A compliant physician query must:
Answer: B
Explanation:
A compliant query is designed to clarify the record without steering the provider to a predetermined answer. ACDIS-aligned standards stress two essentials: neutrality (non-leading phrasing) and clinical support (relevant indicators). Clinical indicators might include vitals, labs, imaging, medications, documented symptoms, problem list history, or assessment findings that create the need for clarification. The query should present the inconsistency or ambiguity, reference the supporting facts, and offer clinically reasonable answer choices including "other" and "unable to determine" when appropriate. This structure protects documentation integrity and reduces regulatory risk, because leading queries can be interpreted as directing documentation for payment rather than accuracy. Verbal-only queries are not sufficient when they affect coding; CDI programs typically require a documented query trail per policy. Purely open-ended questions without context are also problematic because they do not show why clarification is needed and may not be actionable. Proper non-leading, indicator-supported queries improve accuracy of diagnosis specificity, severity capture, and defensibility in audits while preserving provider autonomy.
NEW QUESTION # 133
If a patient is being seen for follow-up and the documentation indicates that the patient was admitted to the hospital 28 days ago with an acute cerebral infarction with remaining right-sided weakness, which of the following diagnoses would be MOST appropriate?
Answer: B
Explanation:
In the outpatient follow-up setting, when the acute stroke event has occurred in the recent past and the patient is now being evaluated for residual deficits, documentation and coding should focus on the sequelae (late effects) rather than re-coding the acute infarction itself-unless the provider clearly states the stroke is still in the acute phase and being actively treated as such. ACDIS outpatient CDI principles stress selecting the diagnosis that best reflects the reason for today's encounter and the condition being assessed/managed. Here, the ongoing clinical issue driving follow-up care is the persistent neurologic deficit (right-sided weakness/hemiparesis) after the cerebral infarction. Option C is the most specific and clinically accurate because it captures (1) the relationship to the prior cerebral infarction ("following cerebral infarction") and (2) laterality and dominance ("right dominant side"), which improves code specificity and reflects functional impact. Option A incorrectly keeps the focus on an unspecified cerebral infarction rather than the residual deficit, and option D is too nonspecific compared with a clearly described hemiparesis.
NEW QUESTION # 134
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: D
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 # 135
Symbicort is used to treat which of the following conditions?
Answer: C
Explanation:
Symbicort is an inhaled combination medication containing an inhaled corticosteroid (ICS) and a long-acting beta-agonist (LABA). In outpatient chart review, this medication class is most strongly associated with chronic airway inflammatory diseases requiring controller therapy-especially persistent asthma (and also maintenance therapy for COPD, though COPD is not an option here). For CDI purposes, medication-to-diagnosis linkage can act as a clinical indicator supporting clarification when the visit note lists respiratory symptoms but does not clearly document the chronic condition being treated or its acuity/status. Symbicort is not used to treat musculoskeletal degenerative disease (osteoarthritis), peripheral nerve pain from diabetes (diabetic neuropathy), or cardiac pump failure (congestive heart failure). When Symbicort appears on the active med list, outpatient CDI commonly checks that the provider's documentation appropriately reflects asthma classification (intermittent vs persistent), current control, exacerbation status if applicable, and that the condition is being monitored/assessed/treated during the encounter to support reportability and accurate coding.
NEW QUESTION # 136
How does accurate documentation impact APC assignment in outpatient services?
Answer: C
Explanation:
In hospital outpatient settings paid under OPPS, Ambulatory Payment Classifications (APCs) are influenced by the coded services and, in many workflows, the clinical documentation that supports correct CPT/HCPCS selection, units, modifiers, and-when applicable-medical necessity linkages to diagnoses. Accurate documentation ensures that the record supports what was actually performed (e.g., complexity, laterality, supplies, drug administration details, observation criteria, or separately payable procedures) and that coding can correctly apply bundling/packaging rules without losing legitimately reportable services. While APCs are primarily procedure-driven, documentation remains decisive because incomplete or ambiguous notes lead to downcoding, missed charges, incorrect status indicators, or denials during medical review. From an outpatient CDI standpoint, the goal is to ensure the clinical story supports codeable services and their necessity: clear indications, findings, assessment/plan, and any required elements (time, start/stop, dose/route for medications, device details, etc.). This supports appropriate APC grouping and reimbursement integrity, reducing rework, denials, and compliance risk.
NEW QUESTION # 137
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