ACDIS CCDS-O key terms

A diagnosis grouping used in risk-adjustment payment models; each enrollee's documented conditions map to categories that predict future cost and set capitation payment.

A numeric value summarizing the predicted cost of caring for a patient, calculated from documented HCCs, demographics, and model version; it drives payment in Medicare Advantage and similar plans.

A documentation test for whether a condition can be reported: the record must show Monitoring, Evaluation, Assessment, or Treatment of that condition during the encounter, not merely a past-history mention.

An alternative documentation standard requiring Treatment, Assessment, Monitor, Plan, Evaluate, or Referral evidence before a chronic condition is coded; often applied to risk-adjustment audits in place of MEAT.

The CDI and provider process of reviewing the cumulative problem list against visit notes to resolve stale, duplicated, resolved, or conflicting diagnoses before coding and billing.

A diagnosis a provider is considering but has not confirmed; outpatient coding rules generally prohibit reporting it as confirmed, so CDI prompts clarification of status and workup.

An ICD-10-CM code used when the record lacks detail to assign a more specific code; frequent use signals documentation gaps that outpatient CDI should address through clarification.

The level of clinical detail in a diagnosis code, such as laterality, severity, or type; higher specificity improves payment accuracy, quality reporting, and risk-adjustment capture.

A written or verbal request from CDI or coding staff asking a provider to clarify or add documentation, ideally non-leading and supported by clinical indicators in the record.

Objective evidence in the record, such as lab values, imaging results, or vital signs, that supports a diagnosis and justifies a query when documentation is ambiguous or incomplete.

The work of building trust and collaboration with physicians so they accept CDI feedback, respond to queries, and adopt documentation habits that reflect the care they deliver.

Targeted teaching for clinicians and staff on documentation standards, coding impacts, and query response, usually delivered through brief sessions, specialty-specific examples, and feedback reports.

A structured note format that prompts clinicians for required clinical elements, reducing omissions and supporting accurate code assignment without encouraging cloned or copy-pasted content.

Reusing prior note text in a new encounter; it creates risk of outdated or unsupported diagnoses and is a common audit finding that outpatient CDI must detect and correct.

The complexity of establishing diagnoses, assessing data, and selecting management options; it is a component of outpatient E/M level selection and a focus of CDI review.

The service intensity category assigned to an outpatient visit, determined under current rules by either medical decision making or total time on the date of the encounter.

Selecting an E/M level using the total minutes spent on the encounter date on practitioner activities, including documentation and care coordination, rather than MDM elements.

A clinic owned or operated by a hospital and billed under the outpatient prospective payment system; CDI there must align facility and professional documentation and code sets.

A two-digit code on a claim identifying where the service occurred, such as office or hospital outpatient; it affects payment and which coding rules apply.

The split between the hospital's facility code assignment for resources used and the physician's professional code assignment for the service; CDI must support both consistently.

The patient's stated reason for the visit, recorded in the patient's own words; it anchors the emergency department note and guides history and diagnostic workup.

The chronologic description of the patient's current problem, including onset, location, duration, severity, and modifying factors; its completeness supports diagnosis and level of service.

A systematic inventory of body-system symptoms reported by the patient or caregiver; in the emergency department it is often abbreviated and must be documented rather than assumed.

The record of prior conditions, family illnesses, and social factors such as tobacco or housing; it supports risk capture and identifies conditions needing monitoring or treatment.

Concurrent review of ED documentation to ensure presenting problems, workups, and final diagnoses are clearly stated, since brief encounters and shift changes frequently leave gaps.

A hospital outpatient status for patients needing short-term monitoring and reassessment; it carries different billing rules and requires documentation that supports the decision.

A Medicare inpatient admission standard based on the expectation that the patient will need hospital care spanning at least two midnights; documentation of that expectation is essential.

The physician's documented order to admit a patient as inpatient; it must be present and timely because it determines billing status independent of later documentation.

Review of documentation from video or audio visits, where limited physical exam and remote workflows create specific risks of unsupported diagnoses and incomplete assessment.

Collection and transmission of patient physiologic data from home devices for clinical review; documentation must show the data were interpreted and used in management.

Bundled non-face-to-face services such as chronic care management that require documented care plans, time tracking, and patient consent to be billable.

A preventive visit focused on a personalized prevention plan; it is not a problem-oriented exam, so chronic conditions must still be documented with MEAT to be reported.

Review of ambulatory surgery documentation to confirm preoperative diagnoses, procedure details, and postoperative findings are stated clearly enough to support coding and payment.

The operative or procedural note describing technique, findings, specimens, and complications; missing elements force unspecified codes or lost reimbursement.

The record of anesthetic type, agents, monitoring, and patient response; it supports anesthesia coding and physical status assignment in outpatient surgical settings.

Embedding mental health screening and treatment into primary care; documentation must capture screening results, diagnoses, and collaborative care to support coding and quality measures.

Non-medical factors such as food insecurity, housing, and transportation that affect outcomes; standardized codes exist for them and capture requires clear documentation.