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ACDIS CCDS-O Exam - Topic 2 Question 2 Discussion

When a CDI specialist identifies a discrepancy in documentation, the next step is to:
B) Query the provider for clarification
A) Change the record
C) Escalate to compliance
D) Code the record as is

ACDIS CCDS-O Exam - Topic 2 Question 2 Discussion

Actual exam question for ACDIS's CCDS-O exam
Question #: 2
Topic #: 2
[All CCDS-O Questions]

When a CDI specialist identifies a discrepancy in documentation, the next step is to:

Show Suggested Answer Hide Answer
Suggested Answer: B

CDI staff do not alter the legal health record and should not ''code it as is'' when documentation is unclear, conflicting, or incomplete in a way that impacts accurate reporting. The compliant next step is to issue a provider query for clarification, ensuring the final record accurately reflects the provider's clinical judgment. ACDIS-guided outpatient CDI emphasizes that queries are a quality and compliance tool: they reconcile discrepancies (e.g., conflicting diagnoses across notes, missing linkage between symptoms and conditions, unclear acuity such as ''CHF'' without type/status, or ambiguous infection documentation). The query should be supported by clinical indicators from the chart and should ask the provider to document the clarified diagnosis/status in the record (progress note, addendum, or appropriate attestation). Escalation to compliance is reserved for patterns of nonresponse, suspected integrity concerns, or systemic issues, not routine discrepancies. The objective is to achieve a complete, consistent clinical story that supports coding, risk adjustment, quality reporting, and medical necessity---through provider clarification, not CDI edits.


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Isreal
22 days ago
Totally agree with B!
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Joesph
27 days ago
I thought A was an option too?
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Barney
1 month ago
B is definitely the right move!
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Aaron
1 month ago
Escalating to compliance is too extreme for this step!
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Markus
1 month ago
Wait, you can’t just change the record?
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Avery
2 months ago
No way, it’s B) for sure!
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Aretha
2 months ago
I thought it was A) Change the record?
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Malcolm
2 months ago
Definitely B) Query the provider for clarification.
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Richelle
2 months ago
I’m torn between B and C. I remember we discussed the importance of documentation accuracy, but I’m not clear on when to escalate.
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Chandra
2 months ago
I practiced a question like this where querying was emphasized, so I lean towards B too, but I wonder if there are exceptions.
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Ona
2 months ago
I feel like changing the record isn't the right approach, but I can't recall if escalating to compliance is necessary in every case.
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Yolando
3 months ago
I think the right answer might be B, but I'm not completely sure. I remember something about querying providers in similar practice questions.
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