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ACDIS Certified Clinical Documentation Specialist-Outpatient Sample Questions (Q46-Q51):
NEW QUESTION # 46
Which of the following actions should be taken when the documentation states: "Hemiparesis, history of CVA, and intracranial trauma?"
- A. Report hemiparesis as sequelae of CVA.
- B. Assign the code for hemiparesis.
- C. Query to clarify the etiology of the hemiparesis.
- D. Report hemiparesis, history of CVA, and history of trauma.
Answer: C
Explanation:
This documentation presents a key outpatient CDI problem: hemiparesis is present, but two potential causal conditions are referenced-history of CVA and intracranial trauma-without clear linkage. In ICD-10-CM, correct reporting of hemiparesis often depends on identifying whether it is a late effect (sequela) of a prior stroke, a residual from traumatic brain injury, or due to another neurologic condition. Coding hemiparesis automatically as a CVA sequela (option A) would be assumptive and potentially inaccurate, because the clinician has not documented the relationship. Likewise, simply coding hemiparesis alone (option D) may miss important etiologic specificity, and coding both histories without clarifying the cause (option B) still leaves the main clinical ambiguity unresolved. Outpatient CDI best practice is to issue a non-leading query requesting provider clarification of the etiology/source of the hemiparesis (e.g., due to prior CVA, due to prior intracranial trauma, both, or other/undetermined). This supports accurate diagnosis reporting, appropriate sequencing, and defensible risk/quality representation.
NEW QUESTION # 47
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?
- A. Assume the conditions are all relevant for this visit.
- B. Query the provider for each of the conditions on the problem list.
- C. Do not code conditions that were pasted from the problem list.
- D. Educate the provider regarding the concerns with copying and pasting this list.
Answer: D
Explanation:
Copy-and-paste of an inpatient problem list into an outpatient note creates significant documentation integrity risks: outdated diagnoses may be carried forward, resolved conditions may appear active, and the note may not clearly show which problems were actually evaluated or managed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.
NEW QUESTION # 48
An 81-year-old is seen by his family physician for continued confusion and poor memory. PMH includes HTN, GERD, and Parkinson's. The provider reviews the neurologist's consultation notes, evaluates the patient's current mental state, and addresses the diagnoses of HTN, GERD, and Parkinson's. The provider's problem list included: Dementia, GERD, HTN, and Parkinson's. Which of the following is the first-listed diagnosis?
- A. HTN
- B. Dementia
- C. GERD
- D. Parkinson's
Answer: B
Explanation:
In the outpatient setting, the first-listed diagnosis is the condition chiefly responsible for the services provided during the encounter. Here, the stated reason for the visit is continued confusion and poor memory, and the provider specifically evaluates the patient's current mental state and references neurology consultation notes-actions that directly support assessment of a cognitive disorder. While HTN, GERD, and Parkinson's are also addressed and may be reportable if they meet encounter relevance (e.g., monitored, evaluated, assessed/managed, or treated), they are not the primary driver for today's visit based on the presenting complaint. Outpatient documentation and coding guidance emphasizes sequencing the diagnosis that best explains the visit's main purpose first, with additional coexisting conditions listed afterward when they impact care. Since "dementia" is on the active problem list and aligns with the patient's cognitive symptoms and the physician's mental-status evaluation, it is the most appropriate first-listed diagnosis among the options.
NEW QUESTION # 49
Which of the following is a key component that is used to calculate Relative Value Units (RVUs)?
- A. Malpractice expense
- B. Physician specialty type
- C. Time with the patient
- D. Medical decision making
Answer: A
Explanation:
RVUs are the foundation of Medicare's physician fee schedule methodology and are built from three core components: physician work (wRVU), practice expense (peRVU), and malpractice (mpRVU). The malpractice expense RVU reflects the relative professional liability insurance cost associated with providing a service and is a defined element of the RVU calculation used to determine payment rates. In outpatient documentation and CDI education, it's important to distinguish what drives code selection versus what is a payment calculation ingredient. Time with the patient and medical decision making influence E/M code selection under current E/M rules, but they are not standalone components of the RVU formula itself-they contribute indirectly by determining which CPT code is billed, and each CPT code has preassigned RVUs. Physician specialty type also is not a direct RVU component, even though specialty patterns can affect typical service mix and overall wRVU productivity. Therefore, among the options, malpractice expense is the explicit RVU component used in the calculation.
NEW QUESTION # 50
What stage of pressure ulcer describes necrosis of soft tissue through the underlying muscle?
- A. 0
- B. 1
- C. 2
- D. 3
Answer: C
Explanation:
A Stage 4 pressure ulcer (pressure injury) is characterized by full-thickness tissue loss with extensive destruction, tissue necrosis, or damage to muscle, bone, or supporting structures. The key phrase in the question-"necrosis of soft tissue through the underlying muscle"-signals a depth of injury that extends beyond the subcutaneous tissue and involves muscle, which is consistent with Stage 4. By comparison, Stage 2 involves partial-thickness skin loss with exposed dermis (no necrosis through deeper structures). Stage 3 involves full-thickness skin loss where adipose may be visible, but muscle, tendon, or bone are not exposed; undermining and tunneling may occur, yet the defining line is that it does not extend to muscle/bone involvement. "Stage 5" is not part of standard pressure ulcer staging used in coding and documentation. Outpatient CDI practice emphasizes documenting the exact stage, anatomic location, laterality when applicable, and whether the ulcer is healing or complicated (infection/osteomyelitis) because stage drives specificity, severity capture, and appropriate care planning documentation.
NEW QUESTION # 51
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