Prepare to pass the CDEO with outpatient documentation-improvement practice

Answer:

Pre-visit reviews look at the record before an appointment to flag conditions that may need to be addressed, while retrospective reviews look at documentation after the visit. Both must follow compliant query rules and may not lead the provider. A misstates who performs it. B is wrong, since retrospective reviews are common. C ignores the timing difference.

Source: ACDIS outpatient CDI practice resources; AHIMA/ACDIS Guidelines for Achieving a Compliant Query Practice (2022 update)

Answer:

Pre-visit reviews may point out clinical indicators for the provider to evaluate, but they may not lead the provider to a single diagnosis or add diagnoses on the provider's behalf. A and C create diagnoses without the provider. B leads the provider to a specific answer.

Source: AHIMA/ACDIS Guidelines for Achieving a Compliant Query Practice (2022 update); ACDIS outpatient CDI practice resources

Answer:

The share of unspecified codes is a common measure of documentation specificity. A falling rate suggests providers are documenting details such as type, acuity, and laterality. B, C, and D are measured in other ways. Some unspecified codes are appropriate when details are not yet known.

Source: ACDIS CDI program metrics guidance; ICD-10-CM Official Guidelines for Coding and Reporting FY2027, Section I.B.18