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ACDIS Certified Clinical Documentation Specialist-Outpatient Sample Questions (Q77-Q82):

NEW QUESTION # 77
A patient is seen at the clinic for a fever, and the provider documents possible Zika virus. A CDI specialist reviews the record and notes that a positive serology test indicates the Zika virus. Which of the following should the CDI specialist do NEXT?

Answer: B

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.


NEW QUESTION # 78
When should the assignment of a not elsewhere classified (NEC)/other specified code be reported?

Answer: C

Explanation:
In outpatient CDI and ICD-10-CM coding guidance emphasized in ACDIS education, "NEC" (Not Elsewhere Classified) aligns with the "other specified" options in the code set and is used when the provider's documentation is clinically specific, but the classification system does not offer a unique code for that exact specificity. In other words, the record contains enough detail to describe a distinct type, cause, manifestation, or clinical variation of a condition, yet there is no more precise code available, so the "other specified" category appropriately captures that documented specificity. This is the opposite of "unspecified" (often associated with "NOS"), which is selected when the documentation is not detailed enough to choose a more specific code option. From a chart review perspective, NEC/other specified supports accurate reporting because it reflects that the clinician did document additional detail, and the coder is not defaulting to unspecified due to missing documentation-rather, the code set itself limits further granularity.


NEW QUESTION # 79
Calculate the expected yearly cost for this patient based on the RAF score.

Answer: B

Explanation:
In outpatient risk adjustment (commonly Medicare Advantage), the patient's predicted cost is derived from the Risk Adjustment Factor (RAF), which is the sum of component risk contributions. Here, the RAF is calculated by adding the HCC diagnoses score (0.166), disease interactions (0.112), and demographic score (0.330). That total equals 0.608. The PMPM (per-member-per-month) baseline cost is $800. To estimate the patient's expected monthly cost, multiply PMPM by RAF: $800 × 0.608 = $486.40 per month. The question asks for the expected yearly cost, so convert PMPM to annual: $486.40 × 12 = $5,836.80. ACDIS outpatient CDI teaching emphasizes that accurate documentation and compliant coding directly affect RAF through captured HCCs and interactions (when supported), which in turn drives expected resource needs and plan payment. Missing or unsupported diagnoses can understate RAF; vague documentation can prevent valid HCC capture.


NEW QUESTION # 80
Which of the following is covered under the Outpatient Prospective Payment System (OPPS)? (Select all that apply)

Answer: B

Explanation:
Under Medicare, OPPS is the payment system used primarily for hospital outpatient department (HOPD) services paid under APCs, and it also applies to a limited set of non-hospital entities for specific covered services. Community Mental Health Centers (CMHCs) are included under OPPS for certain outpatient mental health services, most notably partial hospitalization-type services that are paid using OPPS methodology, which is why CMHCs are considered "covered under OPPS" in many outpatient CDI education materials. In contrast, clinical diagnostic laboratory services are generally excluded from OPPS and paid under the Clinical Laboratory Fee Schedule (with separate billing and payment rules). Indian Health Services follow different statutory and payment structures and are not paid broadly under OPPS in the same way as HOPDs/CMHC OPPS services. Physical therapy reimbursement is typically governed by therapy-specific rules and fee schedule methodologies rather than being a standard OPPS-covered category in this context. Therefore, among the listed options, CMHCs are the correct OPPS-covered selection.


NEW QUESTION # 81
Given the following CMS-HCC categories, which is the correct order (highest to lowest) in the hierarchy?

Answer: B

Explanation:
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.


NEW QUESTION # 82
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