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ACDIS CCDS-O Exam - Topic 2 Question 2 Discussion
Topic #: 2
When a CDI specialist identifies a discrepancy in documentation, the next step is to:
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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