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Certified Clinical Documentation Specialist-Outpatient (CCDS-O)

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Certified Clinical Documentation Specialist-Outpatient (CCDS-O) Questions and Answers

Questions 1

Upon retrospective review of a patient visit 2 weeks prior, a CDI specialist notes physician documentation stating the following: “Sick Sinus Syndrome in 2016 s/p pacemaker placement. Latest EKG shows normal paced rhythm.” There are no codes noted for Sick Sinus Syndrome or the pacemaker. Which of the following is the BEST course of action for the CDI specialist?

Options:

A.  

Capture code for pacemaker status only.

B.  

Request the provider amend the codes to reflect the Sick Sinus Syndrome and pacemaker status.

C.  

Educate the provider that a pacemaker status code as well as a Sick Sinus Syndrome code should be assigned.

D.  

Ask the coder to re-bill based upon the documentation.