ACDIS CCDS-O flashcards

32 cards. Read the term and the definition here. The deck at the top of this page is optional.

MEAT criteria

A documentation framework requiring Monitoring, Evaluation, Assessment, or Treatment for a diagnosis to be considered reportable and clinically valid in the outpatient record.

HCC capture

Hierarchical condition category risk adjustment requires chronic conditions to be documented and assessed at least once per calendar year; a problem list entry alone is insufficient.

Diabetes linkage

Documentation must link diabetes to its complications (e.g., 'diabetes with retinopathy') to capture the complication HCC; separate listings without linkage may not suffice.

CKD staging

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

BMI coding

BMI codes (Z68.xx) are reportable only when documented by the provider; the clinical diagnosis of obesity (e.g., E66.9) must also be documented to support coding.

Problem list review

The annual wellness visit should include a review of the complete problem list and assessment of chronic conditions to support accurate HCC capture and quality reporting.

Causal linkage terms

Terms such as 'due to,' 'secondary to,' or 'with' establish a causal relationship between conditions; CDI specialists should not assume linkage without explicit documentation.

Provider documentation source

In physician practices, the provider's documentation is the source of truth for code assignment; the CDI specialist clarifies but does not assign diagnoses independently.

Facility vs. professional

Hospital clinic encounters may be billed under the facility NPI or the physician's professional claim; documentation requirements differ between the two components.

E/M MDM

Office/outpatient E/M level selection is based on medical decision making (problems addressed, data reviewed, risk) or total time on the date of the encounter.

Chronic care management

CCM services require documented time, a care plan, and patient consent; CDI review should verify these elements are present in the record.

Transitional care management

TCM requires documentation of interactive contact, medication reconciliation, and a face-to-face visit within the specified timeframe after discharge.

High-risk cohorts

Clinic CDI often targets oncology, transplant, and heart failure patients where documentation of severity, staging, and treatment response affects risk adjustment and quality metrics.

Compliant query practice

A compliant query is non-leading, includes clinical indicators, and offers options without introducing new diagnoses; it supports clarification of ambiguous documentation.

Problem-oriented documentation

Each chronic condition assessed in a clinic visit should state its status (stable, improved, worsening, uncontrolled) to support code specificity and clinical validity.

Hospital clinic scope

Hospital clinic CDI applies to ambulatory settings owned or operated by the hospital, such as cardiology, oncology, and surgery clinics, where facility and professional rules intersect.

ED final impression

The ED final impression may differ from the admitting or discharge diagnosis; CDI specialists should focus on the ED provider's documented final diagnosis.

Critical care time

Critical care codes (99291/99292) require documentation of the critical illness or injury and total time spent providing critical care.

ED sepsis documentation

Sepsis in the ED requires documentation of the infection source and organ dysfunction; a single lactate or screening tool alone does not establish the diagnosis.

ED procedure documentation

Procedures such as laceration repair or incision and drainage require separate documentation of site, size, and complexity to support procedure codes.

Observation status

The ED physician may order observation status; CDI specialists should not conflate ED encounter documentation with subsequent inpatient documentation.

ED MDM statement

A medical decision-making statement summarizing the differential, data reviewed, and risk supports both the E/M level and clinical validity of the ED encounter.

Common ED presentations

Chest pain, abdominal pain, and respiratory symptoms are frequent ED presentations; documentation of workup, results, and final impression supports the most specific diagnosis.

ED E/M level

ED E/M level is based on medical decision making (problems, data, risk) or total time; documentation must reflect the complexity actually managed.

Telehealth documentation

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

Urgent care CDI

Urgent care documentation should capture the presenting problem, workup, and disposition to support the level of service, similar to but narrower than the ED.

Home-based primary care

Documentation in home-based primary care should capture the home environment, caregiver involvement, and functional status, which affect risk adjustment and care planning.

Remote patient monitoring

RPM services require documentation of device setup, data review, and time spent; CDI review should verify these elements are present.

Preventive visit documentation

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

Quality measure overlap

Quality measures (HEDIS, MIPS) often overlap with CDI; conditions such as hypertension, diabetes, and depression should be 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.

Other outpatient settings

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