ACDIS CCDS-O cheat sheet

Physician practice CDI focuses on the medical record as the source of truth for code assignment; the coder translates documented diagnoses, not the CDI specialist.

Hierarchical condition category (HCC) capture: chronic conditions must be documented and assessed at least once per calendar year for risk adjustment; a diagnosis listed in the problem list without an assessment does not establish active status.

MEAT criteria for a reportable diagnosis: Monitoring (signs, symptoms, disease progression), Evaluation (test results, medication response), Assessment (status, staging, description), Treatment (medications, therapies, referrals).

Specificity rules: document diabetes type (1, 2, secondary) and any associated complications (retinopathy, neuropathy, CKD) as linked; unspecified diabetes does not capture the complication HCC.

Chronic kidney disease must be staged (1-5, ESRD); stage 3 unspecified (N18.30) is less specific than stage 3a (N18.31) or 3b (N18.32).

Body mass index (BMI) codes are reportable only when documented by the provider; BMI alone does not establish obesity-document the clinical diagnosis (e.g., E66.9) and the BMI code (Z68.xx) together.

Linkage terms such as 'due to,' 'secondary to,' or 'with' establish causal relationships; avoid assuming linkage when the note lists conditions separately without a stated relationship.

Annual wellness visit (AWV) documentation should include a complete problem list review and assessment of chronic conditions to support accurate HCC capture and quality measure reporting.

Hospital clinic CDI applies to ambulatory settings owned or operated by the hospital (e.g., cardiology, oncology, surgery clinics) where facility and professional coding rules intersect.

Place-of-service and facility vs. professional components: the clinic CDI specialist must know whether the encounter is billed under the hospital's facility NPI or the physician's professional claim, because documentation requirements differ.

E/M level selection: medical decision making (MDM) or total time on the date of the encounter drives the 2021+ office/outpatient E/M codes; documentation must support the elements counted.

Problem-oriented documentation: each chronic condition assessed should state status (stable, improved, worsening, uncontrolled) to support both code specificity and clinical validity.

Care management services (e.g., chronic care management, principal care management) require documented time, care plan, and patient consent; CDI review should verify these elements exist.

Transitional care management (TCM) requires documentation of interactive contact, medication reconciliation, and face-to-face visit timing within the specified window.

Clinic CDI often targets high-risk cohorts (oncology, transplant, heart failure) where documentation of severity, staging, and treatment response affects both risk adjustment and quality metrics.

Query practice: use a compliant, non-leading query when documentation is ambiguous; include the clinical indicators and offer options without introducing new diagnoses.

ED CDI focuses on documentation of presenting symptoms, differential diagnoses, and the final impression; the final diagnosis in the ED record may differ from the admitting or discharge diagnosis.

E/M level in the ED is based on MDM (problems addressed, data reviewed, risk of complications) or total time; documentation must reflect the complexity actually managed.

Critical care (99291/99292) requires documentation of the critical illness or injury and the care provided; time-based code requires total time documented.

Observation vs. inpatient status: the ED physician may order observation; CDI should not conflate ED encounter documentation with subsequent inpatient documentation.

Sepsis in the ED: documentation must support the diagnosis and the clinical criteria (e.g., infection source, organ dysfunction); avoid coding sepsis based on a single lactate or a screening tool alone.

Chest pain, abdominal pain, and respiratory symptoms are common ED presentations; document the workup, results, and final impression to support the highest specific diagnosis.

Procedures performed in the ED (e.g., laceration repair, incision and drainage) require separate documentation of the procedure, site, size, and complexity to support procedure codes.

ED documentation should include a medical decision-making statement summarizing the differential, data reviewed, and risk, which supports both code level and clinical validity.

Other outpatient settings include telehealth, urgent care, retail clinics, and home-based primary care; documentation standards remain the same, but modality-specific requirements apply.

Telehealth: documentation must include the modality (audio-video vs. audio-only), patient location, and consent; audio-only visits may have different code sets and coverage rules.

Urgent care: similar to ED but often with a narrower scope; document the presenting problem, workup, and disposition to support the level of service.

Home-based primary care: documentation should capture the home environment, caregiver involvement, and functional status, which affect both risk adjustment and care planning.

Remote patient monitoring (RPM) and other digital health services require documentation of device setup, data review, and time spent; CDI review should verify these elements.

Annual wellness visits and preventive visits in any outpatient setting require documentation of the personalized prevention plan and risk factors to support code selection.

Quality measure documentation (e.g., HEDIS, MIPS) often overlaps with CDI; ensure conditions such as hypertension, diabetes, and depression are documented with status and control.

Setting-specific query practice: in telehealth and urgent care, documentation may be brief; CDI specialists should use targeted queries to clarify ambiguous diagnoses without delaying the encounter.