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Given the following CMS-HCC categories, which is the correct order (highest to lowest) in the hierarchy?
In the CMS-HCC model, certain disease groupings are arranged in hierarchies so that when multiple related conditions are reported for the same patient, only the most severe (highest-ranked) HCC in that hierarchy is counted for risk adjustment. This prevents ''double counting'' of clinically related conditions that represent the same underlying burden of illness. The cancer-related HCCs in the 35--38 range are an example of this hierarchical design: if a patient has diagnoses that map to more than one of these HCCs, the model retains the highest-ranked category and suppresses the lower ones. Therefore, the correct hierarchy order is from the most severe category (HCC 35) down sequentially through HCC 36, HCC 37, and HCC 38. From an outpatient CDI perspective, this reinforces why accuracy and specificity matter: documentation should clearly establish the most clinically severe, active, and treated condition so the correct (highest) HCC is captured, rather than relying on nonspecific or less severe descriptors that could under-represent patient complexity.
In review of a clinic record, a CDI specialist notes the provider has directly copied and pasted a previous inpatient problem list into the current ambulatory visit note. Which of the following is the CDI specialist's BEST course of action?
Copy-and-paste of an inpatient problem list into an outpatient note creates significant documentation integrity risks: outdated diagnoses may be carried forward, resolved conditions may appear active, and the note may not clearly show which problems were actually evaluated or managed during the current encounter. Outpatient CDI best practice is not to assume relevance (eliminating D) and not to reflexively query every listed diagnosis (B), which can be burdensome, non-targeted, and may lead to ''query fatigue.'' Likewise, blanket instruction to ''not code'' anything pasted (A) is not appropriate because some conditions may still be active and reportable if the provider documents assessment/management (e.g., monitoring, evaluation, addressing, or treatment). The most effective and sustainable action is provider education: explain why indiscriminate copy-forward threatens accuracy, compliance, medical necessity support, quality reporting, and risk adjustment validity; reinforce documenting current status and care provided for each active condition; and encourage updating the problem list and assessment to reflect what is truly addressed at the visit. Targeted queries can still be used when specific contradictions or high-impact ambiguities are identified.
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A patient is scheduled to see his PCP in 3 days. A CDI specialist notes that during the patient's last visit earlier this year, the problem list shows both DM 2 associated erectile dysfunction and DM 2 without complications. The last clinic note states that DM 2 with autonomic neuropathy was addressed. The CDI specialist should do which of the following FIRST?
The record contains conflicting documentation: the problem list includes both ''type 2 diabetes without complications'' and diabetes with complications (erectile dysfunction association), while the most recent clinic note indicates the provider addressed ''DM2 with autonomic neuropathy,'' which is clearly a diabetic complication. In outpatient CDI, the first priority is to resolve internal inconsistency so coding accurately reflects the patient's current clinical status and what was evaluated/managed at the encounter. A query should therefore focus on whether the patient's diabetes is with complications (and which complications are active/being addressed) versus truly without complications, because ''without complications'' is generally not appropriate when neuropathy/other manifestations are present and being managed. CDI staff also should not unilaterally remove items from the provider-maintained problem list, and asking the patient is not a reliable documentation/coding source for establishing diagnoses. Once the provider clarifies diabetes complication status, a follow-up clarification can address specific linkages (e.g., erectile dysfunction due to diabetes) if needed for correct code assignment
A CDI specialist receives a call from a disgruntled provider regarding recent documentation queries. The provider claims to only have 15 minutes to see patients and does not have time for interruptions like this if it does not increase reimbursement. Which of the following is the BEST course of action to effectively facilitate communication?
Effective outpatient CDI depends on provider engagement, efficient workflows, and respectful communication. When a provider is frustrated about time pressures, the most productive approach is to partner with them to reduce friction while preserving compliant documentation improvement. ACDIS outpatient CDI concepts emphasize collaboration and provider education---meeting the provider where they are, understanding their workflow constraints, and jointly designing a query process that is minimally disruptive (e.g., batching queries, aligning with clinic schedules, using prospective queries, leveraging templates, or routing through agreed channels). Option C directly addresses the root issue (workflow burden) and builds trust by seeking the provider's input and scheduling the discussion at their convenience. Option A is confrontational and frames CDI as a compliance demand rather than a clinical accuracy initiative. Option B is inappropriate because CDI cannot stop querying when clarification is needed for accurate documentation, coding, quality reporting, and risk adjustment. Option D escalates prematurely and damages relationships; escalation is typically reserved for persistent, unresolved non-responsiveness after collaborative efforts and leadership-supported education.
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Which of the following therapies is MOST likely to be recommended?
Metoprolol is a beta-blocker commonly used in atrial fibrillation to achieve ventricular rate control, reduce symptoms (palpitations, dyspnea), and improve hemodynamic stability, especially when the rhythm is persistent or recurrent. From an outpatient CDI chart-review perspective, therapy-to-diagnosis consistency is a key clinical indicator that supports clarifying the condition being treated and ensuring it is documented as assessed/managed at the encounter. The other options are clinically mismatched: ''Ensure'' is a nutritional supplement typically used for inadequate intake or weight loss and would not be recommended for morbid obesity; rivaroxaban (Xarelto) is an anticoagulant and would be inappropriate in the setting of hematemesis (active GI bleeding) where anticoagulation generally increases risk and would typically be held or reassessed; tamoxifen is an endocrine therapy for hormone receptor--positive breast cancer risk/treatment and is not a standard therapy for chronic congestive heart failure. Therefore, metoprolol for atrial fibrillation is the most appropriate and likely recommendation among the choices.
140 questions covering all exam domains, starting from $20
5 domains from the ACDIS CCDS-O exam outline, with approximate weightings. Every sample question above is tagged with the domain it comes from
Master the Official Guidelines for Coding and Reporting including first-listed and secondary diagnoses, reportable diagnosis criteria, and documentation from non-providers. Understand OPPS code sets, ambulatory payment classifications, and the distinction between inpatient and observation status. Apply CPT and ICD-10-CM concepts to medical necessity, claims submission, and Medicare Physician Fee Schedule reimbursement.
Identify clinical indicators and query opportunities across all disease categories from the ICD-10-CM Tabular List, including infectious diseases, neoplasms, endocrine disorders, circulatory and respiratory diseases, and injury/poisoning codes. Recognize pharmaceutical treatments, diagnostic tests without corresponding diagnoses, and standard medical abbreviations as documentation clarification triggers. Perform prospective and retrospective case reviews with awareness of common primary care documentation gaps.
Demonstrate expertise in CMS-HCC risk adjustment including hierarchies, disease interactions, beneficiary demographics, and RAF scoring calculations. Identify diagnoses that qualify as HCCs and understand how documentation impacts risk scores. Track HCC reporting performance, RAF progression, and ACO/MSSP metrics. Apply knowledge of Medicare Advantage capitated payments and compliant CMS-HCC reporting requirements.
Develop effective provider education tools and presentations tailored to departments and services while communicating in a nonconfrontational manner. Track key performance indicators including chart review productivity, query rates, and provider engagement metrics. Analyze outpatient CDI department performance through HCC reporting, RAF scoring, denial rates, and unspecified code usage. Measure impact on physician performance including E/M billing accuracy and risk-adjusted diagnosis capture rates.
Understand population health concepts and CDI collaboration with utilization review and care coordination teams. Explain MSSP and ACO operations, MACRA including MIPS and APMs, and CMS Quality Payment Program measures. Develop compliant outpatient queries adhering to ACDIS guidelines, distinguish between leading and acceptable query formats, and identify when queries are inappropriate. Apply HIPAA confidentiality standards and address OIG and RADV compliance requirements.
Common questions about the exam itself
