| Healthcare regulations, reimbursement, and documentation requirements related to the Official Guidelines for Coding and Reporting, the Outpatient Prospective Payment System (OPPS), and provider coding and billing |
Demonstrate knowledge of the Official Guidelines for Coding and Reporting
- Identify core concepts of a first-listed diagnosis
- Identify core concepts of additional/secondary diagnoses
Identify documentation from non-providers that can be used for code assignment, as described in Section
I.B.14 of the Official Guidelines for Coding and Reporting
- Explain relevant concepts from Section I of the Official Guidelines for Coding and Reporting, including chapter-specific guidelines
- Identify relevant coding principles from Section IV of the Official Guidelines for Coding and Reporting, including uncertain diagnoses, chronic diseases, and codes that describe signs and symptoms
- Define the criteria for what constitutes a reportable diagnosis, as outlined in Section IV of the Official Guidelines for Coding and Reporting, including first-listed and co-existing conditions
Explain the role of AHA Coding Clinic/CPT Assistant in code assignment
Demonstrate knowledge of the OPPS
- Identify services covered under the OPPS
- Identify code sets used in the OPPS
- Identify methodologies used in OPPS reimbursement, including ambulatory payment classifications (APC)
- Demonstrate an understanding of the responsibilities of providers and other clinical staff for documentation necessary for appropriate OPPS reimbursement
- Explain core concepts related to patient status, including inpatient versus observation
Explain professional billing concepts and their application, including:
- Current Procedural Terminology (CPT®) codes, specifically evaluation and management (E/M) and relevant CMS documentation guidelines, and where documentation may be obtained from the medical record
- Understand the basic concepts of the documentation necessary for professional fee reimbursement under the Medicare Physician Fee Schedule, including the relationship of CPT and ICD-10-CM for medical necessity, claims submission, and reimbursement
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| Diseases and disease processes and application to the clinical chart review |
identify and apply clinical indicators and query opportunities related to common medical conditions,
abnormal findings, external causes, and other factors influencing health status, as outlined in the Tabular List
of Diseases and Injuries, including the following:
- Infectious and Parasitic Diseases (A00-B99)
- Neoplasms (C00-D49)
- Diseases of the Blood & Blood-Forming Organs and Certain Disorders Involving the Immune Mechanism (D50-D89)
- Endocrine, Nutritional, and Metabolic Diseases (E00-E89)
- Mental, Behavioral, and Neurodevelopmental Disorders (F01-F99)
- Diseases of the Nervous System (G00-G99)
- Diseases of the Circulatory System (I00-I99)
- Diseases of the Respiratory System (J00-J99)
- Diseases of the Digestive System (K00-K94)
- Diseases of the Skin and Subcutaneous Tissue (L00-L99)
- Diseases of the Musculoskeletal System and Connective Tissue (M00-M99)
- Diseases of the Urinary System (N00-N99)
- Pregnancy, Childbirth, and the Puerperium (O00-O99)
- Certain Conditions Originating in the Perinatal Period (P00-P96)
- Congenital Malformations, Deformations, and Chromosomal Abnormalities (Q00-Q99)
- Symptoms, Signs, and Abnormal Clinical and Laboratory Findings (R00-R99)
- Injury, Poisoning, and Certain Other Consequences of External Causes (S00-T88)
- Factors Influencing Health Status and Contact with Health Services (Z00-Z99)
Identify opportunities for clarification typically presented in primary care visits
Demonstrate the ability to perform prospective and retrospective case reviews and apply knowledge to case
scenarios with clarification opportunities
Recognize common pharmaceuticals/medications and the disease process(es) they treat
Identify diagnostic tests (e.g., labs, radiology, etc.), elements of consult notes, and medications without a
corresponding diagnosis as possible clinical indicators to support documentation clarification opportunities
Recognize standard medical abbreviations used in healthcare settings |
| Risk adjustment models and impact of documentation and coding |
Explain the concept of risk adjustment and its relationship to medical record documentation
- Explain health record elements beyond diagnoses that impact risk scores
- Recognize and define common risk adjustment methodologies including those used by Medicare, Medicaid, and commercial payers
Explain fundamentals of the CMS Hierarchical Condition Category (HCC) risk adjustment model
Describe the principles of the Medicare Advantage program, including capitated payments
Demonstrate an understanding of Medicare risk adjustment factor (RAF) scoring, including how RAF
scores are calculated
Define the following concepts within the CMS-HCC model:
- Hierarchies
- Disease interactions
- Beneficiary demographics (community and institutional)
Explain the parameters and requirements of compliant CMS-HCC reporting
Identify diagnoses that qualify as CMS-HCCs and risk adjust, principally outpatient but also inpatient |
| CDI program concepts: Department metrics and provider education |
Demonstrate an ability to develop succinct, effective provider education
- Identify methods for creating provider education forms and tools
- Demonstrate the ability to produce basic educational presentations specific to departments/services, including providers, clinical staff, and the administration
- Demonstrate the ability to communicate with providers in an effective, nonconfrontational manner
Describe critical performance indicators and data elements that demonstrate the impact of CDI specialist
efforts, including:
- Productivity (number of outpatient chart reviews), query rates, and provider educational sessions conducted
- Rates of diagnoses captured as coded data as a result of CDI intervention
Demonstrate an ability to track and trend data to measure organizational performance over time
Demonstrate the ability to analyze data and evaluate outpatient CDI department performance, including:
- HCC reporting, including HCCs that are dropped, recaptured, and/or newly added over the prior year
- RAF scoring, including progression over baseline and trending
- Accountable Care Organization (ACO) and Medicare Shared Savings Program (MSSP) impact, including
quality scores and performance payments
Identify physician performance metrics, including:
- RAF scores
- E/M billing
- Risk adjusted diagnosis capture rates
- Denial rates for medical necessity of care
- Unspecified code use
- Provider engagement metrics including query response rates, query agreement rates, and problem list updates
Explain how physician documentation impacts publicly reported data (e.g., Hospital Compare, Merit-Based
Incentive Payment System).
Demonstrate a baseline of inpatient CDI knowledge, including basic differences between inpatient and
outpatient coding guidelines |
| Quality, regulatory, and health initiatives |
Demonstrate knowledge of the concepts of population health, including areas of CDI collaboration with
utilization review and care coordination
Define the operations of the MSSP and describe ACOs as well as next generation ACO models
Describe the basic functions of the Medicare Access and CHIP Reauthorization Act (MACRA), including
knowledge of:
- MIPS and Alternative Payment Models (APM)
- Quality reporting, including the CMS Quality Payment Program and its measures
Explain how RAFs impact quality scores and cost-efficiency metrics
Demonstrate an understanding of CDI impact on documentation and code assignment as it relates to quality
reporting
Explain the role of Medicare Contractors, including Medicare Administrative Contractors (MAC) and
Comprehensive Error Rate Testing (CERT) contractors
Demonstrate a foundation in regulatory and association/best practice compliance documents and initiatives
- Demonstrate how to develop a compliant query to the provider, as defined by Queries in Outpatient CDI:Developing a Compliant, Effective Process
- Demonstrate what constitutes a leading query to the provider, as defined by Queries in Outpatient CDI:Developing a Compliant, Effective Process
- Demonstrate an understanding of acceptable provider query formats (e.g., open-ended, multiple choice,and yes/no) and their proper application
- Describe situations in which queries are not appropriate (e.g., diagnosis was not evaluated/ treated/ monitored, etc.) and proper management of diagnoses that lack clinical support, including the process of clinical validation
- Define the goals and objectives of the Medicare Risk Adjustment Data Validation (RADV) Program
- Identify compliance concerns regarding maintenance of the problem list
- Identify areas of potential noncompliance as identified by the Office of Inspector General (OIG) in its Work Plan
- Maintain confidentiality of the medical record and other information relevant to the practice of CDI, including core tenets of HIPAA
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| Official Information |
https://acdis.org/sites/acdis/files/Handbook_CCDS_CCDS-O.pdf |
