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| Section | Weight | Objectives |
|---|---|---|
| Healthcare Regulations, Reimbursement, and Documentation Requirements | 35% | - Alternative payment models: ACO, MSSP, MACRA/MIPS - Provider coding and billing: CPT, Evaluation and Management (E/M), Medicare Physician Fee Schedule - Outpatient Prospective Payment System (OPPS) and Ambulatory Payment Classifications (APCs) - Official Guidelines for Coding and Reporting (OCG) for ICD-10-CM
|
| Clinical Conditions, Pathophysiology, and Chart Review | 20% | - Disease processes across all body systems and documentation relevance - Differentiating acute vs chronic, active vs historical conditions - Clinical indicators, diagnostic tests, medications, and documentation triggers |
| Risk Adjustment Models and Documentation Impact | 25% | - Hierarchies, disease interactions, and compliant HCC reporting - CMS-HCC model fundamentals and RAF scoring - RADV audit concepts and documentation compliance - Medicare Advantage payment structure and documentation requirements |
| CDI Program Concepts, Queries, and Quality | 20% | - CDI metrics: query rates, capture rates, quality scores, denial prevention - Compliant query development: principles, structure, and non-leading language - Regulatory compliance: HIPAA, OIG work plan, confidentiality - Problem list maintenance, provider education, and program operations |
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NEW QUESTION # 18
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 # 19
Which of the following adds weight to the risk score over and above the CMS-HCC weights for individual conditions?
Answer: D
Explanation:
CMS-HCC risk adjustment assigns a baseline coefficient (weight) to each qualifying HCC condition, but certain combinations of conditions can increase predicted cost beyond what would be expected by simply adding the two individual weights. These added increments are captured through disease interaction factors, which apply when specific conditions coexist (for example, diabetes with certain severe complications, or other paired conditions defined by the model). In outpatient CDI, this is why documentation must clearly support both diagnoses-each must be clinically evaluated/managed and meet reporting rules-because accurately capturing the interacting conditions can legitimately increase the beneficiary's risk score. By contrast, hierarchies are designed to prevent double-counting within related condition families (the more severe manifestation typically supersedes a less severe one), which often limits-not adds-separate weights. Resource-based relative values and conversion factors belong to physician fee schedule payment methodology for services/procedures (RVUs and payment conversion), not HCC risk score calculation. Therefore, disease interactions are the correct concept that adds risk score weight beyond individual HCC coefficients.
NEW QUESTION # 20
Provider documentation states: "Type 2 Diabetes with bilateral peripheral arteriosclerotic disease of LE. Bilateral pedal pulses present. Review Hgb A1C and CBC. No change in treatment. Hypertension evaluated and well controlled on Lopressor." Which of the following conditions should be coded?
Answer: B
Explanation:
The documentation explicitly links the conditions by stating "Type 2 Diabetes with bilateral peripheral arteriosclerotic disease of LE," which supports a diabetic circulatory manifestation rather than "diabetes without complications." In outpatient CDI chart review, the word "with" and clear provider linkage allow coding of diabetes "with peripheral angiopathy" (a diabetes complication category) when peripheral arterial/arteriosclerotic disease is documented as associated. In addition, best practice is to code both the diabetes complication category and the specific manifestation when supported, because the manifestation (atherosclerosis of the lower extremities, bilateral) further describes the clinical condition being evaluated. Hypertension is also evaluated and managed ("well controlled on Lopressor"), meeting outpatient reporting expectations for an active condition addressed during the encounter. Option D is incorrect because it double-counts the same concept-peripheral angiopathy already represents a circulatory complication, so adding a separate "diabetes with circulatory complication" statement is redundant rather than additive. Therefore, the correct coding set includes diabetes with peripheral angiopathy, the bilateral lower-extremity atherosclerosis manifestation, and hypertension.
NEW QUESTION # 21
Which of the following diabetic complications requires the assignment of a combination code plus the code for the specific complication?
Answer: D
Explanation:
In ICD-10-CM diabetes coding (as reinforced in outpatient CDI education), some diabetes manifestations are fully captured by a single diabetes "combination" code, while others require a diabetes complication code plus an additional code to identify the specific manifestation. Diabetic nephropathy and many forms of diabetic retinopathy are commonly represented by diabetes combination codes that already describe the manifestation with built-in specificity options (e.g., diabetes with nephropathy; diabetes with retinopathy with/without macular edema and severity). Osteomyelitis, however, is typically captured using a diabetes code such as "diabetes with other specified complication" (e.g., E11.69) to establish the linkage to diabetes and an additional code from the osteomyelitis category (e.g., M86.-) to specify the site, acuity, and type of osteomyelitis. From a chart review standpoint, CDI often queries to confirm the causal relationship ("due to diabetes") and to ensure the osteomyelitis details (site, acute vs chronic) are documented so both codes can be assigned accurately and compliantly.
NEW QUESTION # 22
Documentation from which of the following facility settings contributes to the CMS-HCC risk score?
Answer: B
Explanation:
Under CMS-HCC risk adjustment (commonly applied to Medicare Advantage), qualifying diagnoses must come from acceptable encounter/claim sources and eligible provider types. Hospital-based outpatient services (including a hospital ambulatory clinic) are among the standard, acceptable settings where diagnoses documented, coded, and submitted on qualifying encounters may be used for risk adjustment-assuming they are supported, assessed/managed, and submitted per program requirements. In contrast, certain facility claim types do not typically contribute to CMS-HCC capture in the same way. Hospice care is generally treated as a carve-out/unique payment environment and is not relied upon as a routine source of risk-adjusting diagnosis capture for the member's ongoing RAF. Renal dialysis centers (ESRD facilities) likewise operate under specialized payment constructs and are not the typical outpatient setting used to drive CMS-HCC diagnosis capture for risk adjustment in standard CDI workflows. Freestanding ambulatory surgical centers also frequently fall outside the usual risk-adjustment-eligible encounter sources emphasized in outpatient CDI programs. Therefore, the hospital ambulatory clinic is the correct setting among these choices.
NEW QUESTION # 23
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