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>> ACDIS CCDS-O Latest Exam <<
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NEW QUESTION # 121
A patient receives treatment for diabetes during a primary care visit. He has a glucose level of 240 and A1C of 7.9. The patient is prescribed Gabapentin 100mg TID. Which of the following should the CDI specialist query for?
Answer: A
Explanation:
In outpatient CDI chart review, a key skill is recognizing when medications and treatment plans suggest a specific diabetic complication that is not explicitly documented. Gabapentin is commonly prescribed for neuropathic pain, and in a diabetic patient it is frequently used to treat diabetic peripheral neuropathy symptoms (burning, tingling, numbness, shooting pain). ACDIS outpatient CDI guidance supports querying when there are strong clinical indicators that a more specific, clinically relevant diagnosis may be present and is being treated at the encounter, because diabetes codes require complication specificity when supported (e.g., "diabetes with neuropathy" rather than unspecified diabetes). The elevated glucose and A1C confirm ongoing diabetes management but do not, by themselves, indicate CKD, macular degeneration, or ketoacidosis. Ketoacidosis would require documentation of acute metabolic decompensation and supporting clinical/lab findings, which are not provided here. Therefore, the most appropriate clarification is whether the patient has diabetic peripheral neuropathy (and whether it is painful neuropathy) being managed with gabapentin, so the provider can document the condition clearly and accurately.
NEW QUESTION # 122
Which component of the OPPS assigns payment rates based on procedure grouping?
Answer: C
Explanation:
Under the Medicare Outpatient Prospective Payment System (OPPS), hospital outpatient services are paid based on Ambulatory Payment Classifications (APCs). APCs are the mechanism that groups clinically similar services and procedures-typically identified through CPT/HCPCS reporting-into payment categories with established relative resource costs. CPT codes identify what service was performed, but CPT itself is not the OPPS payment grouping methodology; OPPS takes the coded line items and maps many of them into APC groupings (with packaging rules, status indicators, and modifier impacts) to determine the payment rate. DRGs are used for inpatient prospective payment and do not apply to OPPS outpatient claims in the same way. The Physician Fee Schedule applies to professional services (physician/clinician billing) rather than the hospital facility component paid under OPPS. From an outpatient CDI lens, accurate, specific documentation supports correct CPT/HCPCS selection, modifier use, units, and medical necessity linkages-ensuring services map to the correct APC and are not inappropriately bundled, denied, or downcoded during review. This protects payment accuracy and compliance by aligning the clinical story with the reported outpatient services.
NEW QUESTION # 123
Clinic documentation states: "Follow-up for post-induction chemotherapy for metastatic uterine cancer." To BEST identify the conditions being monitored and treated, a CDI specialist should
Answer: A
Explanation:
When documentation states "metastatic uterine cancer," the most important missing element for complete, accurate outpatient coding is where the cancer has metastasized (the secondary site[s]). In ambulatory CDI, identifying secondary sites best clarifies the full scope of disease being monitored and treated because metastatic disease coding relies on documenting both the primary malignancy and the specific metastatic location(s) (e.g., lung, liver, bone, peritoneum, lymph nodes). This supports correct severity representation, risk capture, treatment intent, and medical necessity for ongoing chemotherapy follow-up. While tumor morphology can be clinically relevant, it is usually established earlier in the diagnostic pathway and does not, by itself, define current metastatic burden. Likewise, reviewing labs or MRI results may provide supportive indicators, but they do not replace provider documentation of the confirmed metastatic sites being managed. A compliant query focused on secondary sites prompts the provider to document the current metastatic disease status (active, responding, progressing) and specific locations, which most directly identifies the conditions under treatment.
NEW QUESTION # 124
A CDI specialist has created the following query:
"Dear Dr., Based on the following clinical indicators: history of CVA and physical therapy ordered to address left sided weakness, please confirm a diagnosis of hemiplegia." What feedback should be given to the CDI specialist regarding the query?
Answer: A
Explanation:
This query is non-compliant because it is leading: it asks the provider to "confirm a diagnosis of hemiplegia," presenting only one targeted outcome rather than requesting clarification in a neutral, clinically appropriate way. ACDIS-aligned outpatient query practice requires queries to be compliant, non-leading, and supported by clinical indicators, typically offering multiple reasonable options (or an open-ended format) and allowing the provider to document the most accurate clinical impression. In this scenario, "history of CVA," "left-sided weakness," and "physical therapy ordered" could reflect several possibilities-such as hemiparesis, residual weakness, post-stroke deficits, deconditioning, or other neurologic impairment-so the query should ask the provider to clarify the nature and diagnosis of the deficit (and laterality), not to confirm a single diagnosis. Option A is incorrect because coding cannot assume hemiplegia without provider documentation. Option C is not the best feedback because indicators can justify clarification. Option D is unnecessary; MRI results are not required for a compliant outpatient query.
NEW QUESTION # 125
For outpatient/provider services, the primary sources of coding authority include the ICD-10-CM Official Guidelines for Coding and Reporting, AHA's Coding Clinic for ICD-10-CM/PCS, as well as which of the following?
Answer: B
Explanation:
Outpatient/provider coding relies on two major code sets: ICD-10-CM for diagnoses and CPT/HCPCS for professional services, procedures, and supplies. Because of that, outpatient coding authority is anchored not only in the ICD-10-CM Official Guidelines and AHA Coding Clinic guidance for diagnosis reporting, but also in the authoritative guidance that clarifies CPT/HCPCS reporting. ACDIS outpatient CDI education stresses that CDI specialists must understand both sides: the diagnosis coding rules (ICD-10-CM) and the procedural/service reporting rules (CPT/HCPCS) that drive much of outpatient reimbursement. AMA's CPT Assistant is a key interpretive authority for CPT coding guidance, while AHA's Coding Clinic for HCPCS provides clarification on HCPCS Level II reporting. The other options focus on ICD-10-PCS guidelines and DRG tools, which are primarily inpatient facility concepts (PCS is inpatient procedure coding; DRGs are inpatient payment groupers). Therefore, the correct supplemental outpatient authority pair is AHA's Coding Clinic for HCPCS and AMA's CPT Assistant.
NEW QUESTION # 126
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