CCDS-O Practice Questions

A query opportunity exists when documentation is conflicting, ambiguous, or incomplete. The documentation "diabetic ulcer of the left great toe" lacks the required ICD-10-CM specificity regarding the depth of the ulcer (e.g., with skin breakdown, fat layer exposed, muscle necrosis, bone necrosis). Clarifying this detail is essential for accurate code assignment (L97.- series) and reflects the severity of illness. While the presence of an ulcer already risk adjusts, capturing the correct severity through a specific code is a key CDI function that impacts data quality and can reflect a higher level of patient complexity.

A. Nicotine dependence

The note states the patient "stopped smoking 2 years ago," which supports a history code, not active dependence.

B. Diabetes with complications

This is already clearly documented with "peripheral neuropathy with diabetic ulcer," which maps to a high-level HCC (HCC 18).

C. Morbid obesity

The documented BMI of 43 is sufficient for a coder to assign the code for morbid obesity (E66.01), which maps to HCC 22.

1. National Center for Health Statistics. (2023). ICD-10-CM Official Guidelines for Coding and Reporting FY 2024. The tabular list for non-pressure chronic ulcers (Category L97) requires a 6th character to specify depth, making this a required element for a valid code.

2. ACDIS/AHIMA. (2019). Guidelines for Compliant Query Practice—2019 Update. This joint practice brief outlines the principles for when a query is appropriate, including when clinical indicators suggest a need for "greater specificity or completeness" (p. 3), as is the case with the unspecified ulcer depth.

CMS risk-adjusted payment = RAF × benchmark. Using the standard benchmark example ($4,864) published in CMS’ MA Rate Announcement and the given RAF of 1.20, yearly cost = 4,864 × 1.20 = $5,836.80.

A. Uses monthly, not yearly, multiplication (4,864 × 0.01).

B. Applies benchmark for aged ESRD ($10,560) instead of the standard; inflates cost.

C. Multiplies by HCC prevalence factor (1.76) rather than the stated RAF of 1.20.

1. CMS. “2024 Medicare Advantage Rate Announcement,” App. VI, Table I: national benchmark rate $4,864 (annual).

2. Pope et al. “Risk Adjustment for Medicare Advantage,” Health Care Fin. Rev. 2004;25(4):119-141 (explains payment = RAF × benchmark).

3. Milliman. “Interpretation of CMS-HCC RAF,” 2022 white paper, p. 3.

The scenario presents a mismatch: the provider's actual costs are high, but the predicted costs, based on the patient panel's average HCC score, are low. The most probable cause for this discrepancy is incomplete or non-specific diagnostic documentation. If the provider's patients are genuinely complex and high-cost, a low HCC score indicates that the chronic conditions, comorbidities, and disease severity that drive up costs are not being accurately captured and reported in claims data. This failure to document all relevant, risk-adjusting diagnoses leads to an artificially low risk score that does not reflect the panel's true acuity.

A. Caring for patients of a higher acuity would explain the high costs, but if documented correctly, it should result in a high HCC score, not a low one.

C. A less complex patient population would explain a low HCC score but would contradict the finding that the provider is "high-cost."

D. While not reporting unspecified diagnoses is good practice, the core issue is the failure to capture any relevant diagnosis, specified or not, that contributes to risk.

1. Poe, B. (Ed.). (2021). The CCDS-O Exam Study Guide (2nd ed.). ACDIS. Chapter 1, "The Outpatient Environment," pp. 6-7, discusses how risk adjustment scores are used to profile providers and how incomplete documentation can lead to scores that don't reflect patient acuity.

2. Berenson, R. A., & Upadhyay, D. K. (2016). Physician-Focused Payment Models: A Road Map for Performance-Based Payment. Urban Institute Research Report. (Section on "Risk Adjustment" discusses the importance of accurate diagnosis coding for fair performance measurement and payment).

3. Swartz, K. (2017). Risk Adjustment and High-Cost Enrollees. The Milbank Quarterly, 95(1), 27–29. https://doi.org/10.1111/1468-0009.12245 (Discusses how failure to accurately capture health status leads to mis-calibration of risk scores relative to actual costs).

A prospective query is initiated prior to or at the time of a patient encounter. In this scenario, the CDI specialist identifies a documentation opportunity and places the query for the ancillary team to address during the upcoming visit. This pre-encounter or point-of-service review aligns with the definition of a prospective review process, which aims to capture accurate documentation concurrently with care delivery in the outpatient setting.

A. Retrospective queries occur after the encounter is completed and billed, reviewing documentation post-discharge or post-visit.

B. Concurrent queries typically refer to reviews conducted during a multi-day inpatient hospital stay, not for a single outpatient visit.

D. Prebill review is a type of retrospective review that occurs after the encounter is complete but before the final bill is submitted.

1. Association of Clinical Documentation Integrity Specialists (ACDIS). (2022). CCDS-O Certification Exam Candidate Handbook. Page 6, Domain 1: Clinical & Coding Practice. "Prospective (pre-encounter) review... Concurrent (point-of-service) review..."

2. ACDIS & AHIMA. (2019). Guidelines for Compliant Query Practice: 2019 Update. Journal of AHIMA, 90(4), page 3. "Prospective queries are... presented to the provider before or at the time of the encounter."

The ICD-10-CM code category N18 is designated for Chronic Kidney Disease (CKD). This category includes specific codes that delineate the stage of the disease based on severity. Correctly included are codes for CKD Stage 3 (N18.3), severe CKD which corresponds to Stage 4 (N18.4), and End-Stage Renal Disease (ESRD), coded as N18.6. The other options incorrectly mix diagnoses from different categories, procedural status codes, or non-diagnostic terms with the N18 category.

A. Polycystic kidney disease is a congenital condition coded in category Q61, and dialysis is a status code (Z99.2), not a diagnosis within N18.

B. GFR (Glomerular Filtration Rate) is a laboratory measurement, not a diagnosis, and ATN (Acute Tubular Necrosis, N17.0) is an acute condition.

C. AKI (Acute Kidney Injury, N17) is an acute condition, and dialysis status (Z99.2) is not a diagnosis in the N18 category.

1. National Center for Health Statistics. (2023). ICD-10-CM Tabular List of Diseases and Injuries. U.S. Department of Health and Human Services, Centers for Disease Control and Prevention. See codes N18.3, N18.4, N18.6.

2. Centers for Medicare & Medicaid Services. (2023). ICD-10-CM Official Guidelines for Coding and Reporting FY 2024. Section I.C.14.a.1. "Chronic kidney disease (CKD) is classified to category N18."

The abbreviation NEC, or "not elsewhere classified," is used when the provider's documentation is specific, but the ICD-10-CM classification system does not have a unique code for the condition. This indicates that the documentation provided more detail than the available codes could represent. It is an "other specified" code. This is distinct from "not otherwise specified" (NOS) codes, which are used when the provider's documentation is not specific enough to assign a more precise code.

A: This describes the use of "not otherwise specified" (NOS) or "unspecified" codes, not NEC codes.

C: This describes the Excludes1 note convention, which indicates that two conditions cannot be reported together.

D: This describes instructional notes such as "code also" or "use additional code," not the purpose of an NEC code.

1. National Center for Health Statistics. (2023). ICD-10-CM Official Guidelines for Coding and Reporting FY 2024. Centers for Disease Control and Prevention. Section I.A.9.a, "Abbreviations: NEC 'Not elsewhere classifiable'," p. 12.

2. World Health Organization. (2019). ICD-10: International Statistical Classification of Diseases and Related Health Problems, Tenth Revision, Volume 2: Instruction Manual. Section 4.2.3, "The ‘not elsewhere classified’ (NEC) convention," p. 29.

According to the ICD-10-CM Official Guidelines for Coding and Reporting for outpatient services, diagnoses documented as "likely," "probable," "suspected," or "rule out" are not to be coded as if they are established. Instead, the coder must report the signs, symptoms, and/or abnormal findings that are documented for the encounter. In this case, the provider documented "likely UTI" and listed the patient's symptoms of abdominal pain, fever, and urinary frequency. Therefore, these signs and symptoms are the correct conditions to be reported for this visit.

A. Pyuria is a laboratory finding, and while it can be coded, the documented signs and symptoms are more specific to the reason for the visit.

B. The diagnosis of UTI is uncertain ("likely") and cannot be coded as a definitive condition in the outpatient setting per official guidelines.

C. E-Coli is not confirmed ("cultures are pending"), and the UTI diagnosis is uncertain. Coding these conditions would be inaccurate.

1. National Center for Health Statistics. (2023). ICD-10-CM Official Guidelines for Coding and Reporting FY 2024. Section IV.I. "Uncertain Diagnosis," p. 118. This section explicitly states not to code uncertain diagnoses in the outpatient setting, but rather to code the signs and symptoms.

The best query opportunity is to clarify the relationship between the diagnosed Urinary Tract Infection (UTI) and the patient's indwelling Foley catheter. The presence of the catheter is a significant clinical factor, and if the provider confirms the link, the diagnosis can be specified as a Catheter-Associated UTI (CAUTI). A CAUTI is a more precise diagnosis that reflects a higher severity of illness and is a critical quality measure. Clarifying this link ensures the most accurate and specific code assignment.

A. Querying the etiology of a chronic condition like BPH is generally not relevant to the acute encounter and is unlikely to impact coding or quality reporting.

C. While the UTI may be causing the back pain, clarifying the cause of the UTI itself (i.e., its link to the catheter) is a more specific and impactful query.

D. Leukocytosis is a lab finding and a clinical sign of the already-diagnosed UTI. Querying for this as a separate diagnosis is redundant.

1. Association of Clinical Documentation Integrity Specialists (ACDIS). (2022). The Clinical Documentation Integrity Specialist's Guide to Queries (3rd ed.). Chapter 3: "When to Query." This guide emphasizes querying for cause-and-effect relationships, such as linking an infection to an indwelling device, to improve diagnostic specificity.

2. Gould, C. V., Umscheid, C. A., Agarwal, R. K., Kuntz, G., Pegues, D. A., & Healthcare Infection Control Practices Advisory Committee (HICPAC). (2010). Guideline for prevention of catheter-associated urinary tract infections 2009. Infection Control and Hospital Epidemiology, 31(4), 319–326. https://doi.org/10.1086/651091. (This guideline defines CAUTI, highlighting the clinical importance of the association).

Compliant physician queries present clinical evidence from the current encounter to prompt the provider for clarification or additional specificity. Offering a new diagnosis as an option in a multiple-choice format is acceptable if it is reasonably supported by the health record's clinical indicators. This practice allows the provider to use their professional judgment to select the most accurate diagnosis based on the evidence presented, without being led to a specific conclusion. The key is that the option must be supported by evidence within the current record.

A. Queries must be based on clinical indicators from the current encounter, not solely on past medical history, to be compliant and clinically valid.

B. Identifying diagnoses as HCCs is considered leading because it links clinical documentation to financial reimbursement, which is non-compliant query practice.

D. A compliant query must include the specific clinical indicators that raise the question, providing context for the provider to make an informed decision.

1. Association of Clinical Documentation Integrity Specialists (ACDIS) & American Health Information Management Association (AHIMA). (2019). Guidelines for Achieving a Compliant Query Practice. Section: "Query Format," pp. 6-7. This brief explicitly states that multiple-choice queries can include options for additional diagnoses not previously documented, as long as they are supported by clinical indicators.

2. ACDIS. (2022). Code of Ethics. Principle 2. This principle requires CDI professionals to facilitate accurate and complete documentation and not lead providers to a specific diagnosis. Omitting indicators (D) or highlighting HCCs (B) would violate this.

The Accountable Care Organization (ACO) will expect to pay back money because its actual costs ($52 million) exceeded its expected cost benchmark ($50 million), resulting in a $2 million loss. In a two-sided risk model, which is common for established ACOs, the organization shares financial responsibility for losses. Even with a high-quality score, no shared savings can be generated when costs are over budget. Therefore, the ACO is liable for a portion of the losses, requiring a payment back to the payer (e.g., CMS).

A. The ACO cannot receive shared savings because its actual costs were higher than its expected costs, meaning no savings were generated.

C. Eligibility for shared savings is determined annually based on performance for that year, not deferred to a future year.

D. Reconciliation for shared savings or losses in programs like the Medicare Shared Savings Program (MSSP) occurs annually, not at the end of the multi-year agreement.

1. Centers for Medicare & Medicaid Services (CMS). (2023). Shared Savings Program. Official CMS documentation details that financial reconciliation is performed annually. An ACO with actual expenditures exceeding its benchmark would not be eligible for shared savings and may be responsible for shared losses.

2. McWilliams, J. M., Hatfield, L. A., Chernew, M. E., Landon, B. E., & Schwartz, A. L. (2016). Early performance of accountable care organizations in Medicare. New England Journal of Medicine, 374(24), 2357-2366. https://doi.org/10.1056/NEJMsa1600142. This study discusses the financial models of ACOs, including the mechanisms for shared savings and losses based on annual performance against benchmarks.