CCDS-O Exam Dumps - ACDIS Clinical Documentation Specialist Questions and Answers

In HCC risk adjustment, chronic kidney disease (CKD) is captured by stage-based HCCs that are hierarchical—only the highest supported CKD stage in the hierarchy is counted for RAF when multiple stages (or a range) are referenced. The documentation includes “CKD – stage 3–4,” which indicates the patient’s baseline CKD severity falls somewhere between stage 3 and stage 4. When selecting from the provided table, stage 4 maps to HCC 327 and is higher than stage 3 categories (HCC 328 for stage 3B and HCC 329 for stage 3 except 3B). AKI due to ATN describes an acute process and does not replace the need to capture baseline CKD stage when it is clinically relevant and documented. Outpatient CDI best practice would be to query the provider to specify the exact CKD stage (since “3–4” is imprecise), but when forced to choose from the hierarchy shown, the correct HCC assignment based on the highest stated stage in the documented range is HCC 327 (CKD stage 4).

The most compliant query is the one that is clinically supported, non-leading, and focused on clarifying documentation for correct reporting and medical necessity—without directing the provider to “add” diagnoses or document conditions for payment purposes. Option A presents relevant clinical context (no GI symptoms; family history) and asks the provider to clarify whether the planned colonoscopy is screening or diagnostic, which is a legitimate documentation clarification affecting correct code selection and coverage rules. It does not imply a desired answer and does not instruct the provider to document additional diagnoses. Option B is problematic because it instructs the provider to “document these conditions” if treated, which can be perceived as prompting and is not tied to encounter-specific indicators. Option C is based primarily on historical information and asks a yes/no about remission, which can be leading and may not reflect current-visit evaluation. Option D effectively asks the provider to add a diagnosis based on nursing documentation, which risks leading language and requires provider confirmation and assessment. Therefore, A is most compliant.