Important ACDIS CCDS-O Exam Questions

Answer: B

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.

Answer: C

Explanation:

In the outpatient setting, diagnoses documented as uncertain (e.g., ''possible,'' ''probable,'' ''suspected,'' ''rule out'') are generally not coded as confirmed conditions; instead, coding is based on confirmed diagnoses or, when not confirmed, the presenting signs/symptoms. Here, the provider documented only ''possible Zika,'' which is not a confirmed diagnosis for outpatient reporting. Even though the CDI specialist sees a positive serology result, lab data alone does not replace provider diagnostic confirmation in the assessment/plan. The appropriate next step is to query the provider to confirm whether Zika is the established diagnosis based on the positive test (and whether it is clinically addressed during the encounter). If confirmed, Zika can be coded appropriately and sequenced based on the reason for the visit; if not confirmed or still under evaluation, the symptom (fever) remains first-listed. Option B is incorrect because coders do not ''code the result'' of a serology test as a diagnosis; they code the condition the test supports once clinically confirmed.

Answer: A

Explanation:

The documented clinical picture and treatment plan better align with pneumonia than uncomplicated bronchitis, creating a clear documentation/coding consistency opportunity. A LLL infiltrate on chest x-ray is a classic clinical indicator for pneumonia, and prescribing levofloxacin supports treatment of a likely bacterial lower respiratory infection rather than routine viral bronchitis. The patient also has fever, dyspnea, cough, and required an in-office nebulizer treatment, all of which can accompany pneumonia and increase clinical significance. In outpatient CDI practice, the most appropriate query is the one that clarifies the provider's definitive diagnosis when objective findings and management suggest a more specific condition than what is stated (e.g., ''possible bronchitis''). Querying for diabetic complications or heart failure specificity is not as directly supported by the encounter's indicators and treatment actions provided, and ''acuity of bronchitis'' is secondary if the true condition is pneumonia. Clarifying whether pneumonia is present ensures accurate reporting, medical necessity support, and appropriate risk/quality capture.

Answer: B

Explanation:

In outpatient CDI, MEAT is a commonly taught framework used to determine whether a condition is sufficiently supported as reportable for a specific encounter. MEAT stands for Monitor, Evaluate, Assess/Address, and Treat. The concept is that diagnoses should not simply be copied forward on a problem list; they should be tied to provider work and clinical relevance during the visit. ''Monitor'' includes reviewing status, trends, or test results related to the condition. ''Evaluate'' includes ordering or interpreting studies, considering disease progression, or documenting response to therapy. ''Assess/Address'' includes documenting stability, exacerbation, or risk and making a plan (education, counseling, referrals). ''Treat'' includes medications, procedures, or other therapeutic interventions. Using MEAT helps CDI staff educate providers to document the current status and management of chronic diseases, supports accurate coding and risk adjustment, and reduces denials by showing medical necessity. OPPS, MACRA, and RADV are important regulatory/payment terms, but they are not the standard acronym used to assess encounter-level reportability.

Answer: C

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.