Free CCDS-O Practice Test Questions 2026

Explanation:
If internal metrics show an increase in HCC query volume and accurate coding is confirmed, yet the organization's RAF scores are decreasing, the issue is likely external—specifically, incomplete transmission of diagnosis codes to the payer. Risk scores are calculated based on the diagnoses the payer receives from claims. If certain codes are not being submitted or are being dropped, the RAF will decline despite correct internal coding.

Correct Option:

A. The payer is not receiving all diagnosis codes
This is correct. Even when CDI efforts result in accurate diagnosis capture and coding, the RAF score used by the payer depends on the codes submitted on claims. If diagnoses are captured internally but not transmitted to the payer (due to claim submission errors, system mapping issues, or payer data ingestion problems), the payer's RAF score will not reflect the full clinical picture, leading to a decrease in the organization's overall RAF.

Incorrect Options:

B. CPT codes are not reflected in the reporting
This is incorrect. CPT codes are used to identify eligible encounters and services but are not directly used in RAF score calculation. RAF scores are driven by ICD-10-CM diagnosis codes mapped to HCCs, not CPT codes. Missing CPT codes would affect reimbursement for procedures but would not directly cause a decrease in RAF scores.

C. CDI specialist queries are validated and compliant
This is incorrect. While it is positive that queries are validated and compliant, this would support accurate coding and should lead to higher RAF scores, not lower. This explanation does not address the disconnect between internal coding and payer-reported RAF.

D. The HCC model has not been updated within the organization
This is incorrect. HCC models are updated periodically by CMS/HHS, but these changes are applied at the payer level, not within the organization. If an organization uses an outdated model internally, it might miscalculate its expected RAF, but the payer calculates RAF based on the current model. This would not explain a decrease in payer RAF scores, especially when internal coding accuracy is confirmed.

Reference:

CMS-HCC Risk Adjustment Model – RAF scores are calculated from diagnosis codes submitted on claims to the payer.

CMS "Risk Adjustment Data Validation (RADV)" – Payers receive diagnosis data via claims; incomplete submission leads to lower RAF scores.

ACDIS/AHIMA "Outpatient CDI" – Internal coding accuracy must align with claims submission to impact payer RAF scores.

HHS-HCC model – RAF scores are based on ICD-10-CM codes submitted to the payer; CPT codes are not used in RAF calculation.

CMS-HCC model updates – Model changes are implemented by CMS and affect payer calculations; internal model updates are not a factor in payer RAF.

Explanation:
The patient has been discharged on home oxygen, but the documentation does not clarify the indication for this therapy—whether it is for hypoxemia, chronic respiratory failure, or dyspnea at rest. This distinction is critical because it determines whether the condition qualifies as an HCC-capturable diagnosis (e.g., chronic respiratory failure) versus a simple symptom (e.g., dyspnea). Clarifying the indication for home oxygen is the most significant query opportunity to ensure accurate risk adjustment and reflect the patient's true clinical severity.

Correct Option:

C. Clarify indication for home oxygen
This is correct. Home oxygen therapy is often prescribed for conditions like chronic respiratory failure (J96.1-), which is a high-weight HCC. However, oxygen can also be prescribed for other reasons, such as dyspnea or symptomatic relief. By querying the provider to clarify the indication for home oxygen, the CDI specialist can capture a specific, high-impact diagnosis (e.g., chronic respiratory failure) that directly affects the RAF score and reflects the patient's true clinical status.

Incorrect Options:

A. Type of the heart failure
This is incorrect. While specifying the type of heart failure (systolic, diastolic, combined) is important, the documentation already includes heart failure as a diagnosis. The immediate and more significant query opportunity is the indication for home oxygen, as it may reveal an underlying HCC (chronic respiratory failure) that is currently undocumented or ambiguous. Heart failure type is secondary to clarifying the oxygen indication.

B. Current status of emphysema
This is incorrect. Emphysema is a form of COPD, which is already documented as "end stage COPD." The status of emphysema is essentially captured by the COPD diagnosis. Querying for emphysema status would not add significant new risk adjustment value compared to clarifying the indication for home oxygen, which may uncover chronic respiratory failure.

D. Oxygen dependence
This is incorrect. Oxygen dependence (Z99.81) is a supplementary factor code that can be coded if documented, but it does not impact risk adjustment significantly. It does not replace the need to clarify the underlying clinical indication for oxygen therapy. Capturing the cause of oxygen dependence (e.g., chronic respiratory failure) is far more impactful than coding oxygen dependence alone.

Reference:

CMS-HCC Risk Adjustment Model – Chronic respiratory failure (J96.1-) is a high-weight HCC; oxygen dependence (Z99.81) is not an HCC.

ICD-10-CM Official Guidelines – Oxygen dependence (Z99.81) is coded when documented, but it does not replace the need for a specific respiratory diagnosis.

ACDIS/AHIMA "Guidelines for Achieving a Compliant Query Practice" – Queries should focus on clinically significant conditions that impact severity, mortality, and risk adjustment; clarifying the indication for oxygen therapy can uncover an HCC.

CMS "Home Oxygen Therapy" documentation requirements – Indication for oxygen (e.g., hypoxemia, chronic respiratory failure) must be documented for medical necessity.

CDI best practices – Prioritize querying for conditions that have high HCC weight and are currently undocumented or ambiguous.

Explanation:
ICD-10-CM coding for diabetes mellitus with complications generally uses combination codes that capture both the diabetes and the manifestation in a single code (e.g., E11.21 for diabetic nephropathy). However, osteomyelitis is a specific infectious/inflammatory bone condition that is not inherently part of the diabetes combination code structure. When diabetes is documented with osteomyelitis, you must assign a combination code for diabetes with other specified complication (E11.69) plus a separate code for the osteomyelitis (M86.-) to fully capture the condition.

Correct Option:
D. Osteomyelitis

This is correct. ICD-10-CM guidelines require that when a patient has diabetes and osteomyelitis, you assign:

A combination code for diabetes with other specified complications (E11.69) to indicate the diabetes is associated with the osteomyelitis.

A separate code for the osteomyelitis (M86.-) to specify the site and type.

This is because osteomyelitis is a specific infectious bone condition that is coded separately, unlike nephropathy or retinopathy which have dedicated combination codes.

Incorrect Options:

A. Nephropathy
This is incorrect. Diabetic nephropathy has a dedicated combination code (e.g., E11.21 for Type 2 diabetes with diabetic nephropathy). No additional code is needed for the nephropathy itself, as it is fully captured by the combination code.

B. Retinopathy
This is incorrect. Diabetic retinopathy has a dedicated combination code (e.g., E11.311 for Type 2 diabetes with unspecified diabetic retinopathy with macular edema). No separate code for retinopathy is required; the combination code captures both the diabetes and the eye condition.

C. Dermatitis
This is incorrect. Diabetic dermatitis (e.g., diabetic skin complications) is coded with a combination code for diabetic skin complications (E11.62) or diabetic dermatitis (E11.620). No additional code is needed for the dermatitis itself, as it is included in the combination code.

Reference:

ICD-10-CM Official Guidelines for Coding and Reporting – Section I.C.4.a.3 – Diabetes with other specified complications (E11.69) requires an additional code to identify the specific complication (e.g., osteomyelitis).

ICD-10-CM Guidelines – Diabetic nephropathy (E11.21) and retinopathy (E11.31-) are combination codes that do not require an additional code for the manifestation.

ICD-10-CM Guidelines – Diabetes with skin complications (E11.62) is a combination code; dermatitis is included in this category.

ICD-10-CM Tabular List – E11.69 (Type 2 diabetes with other specified complications) is used with an additional code for the specific condition (e.g., M86.- for osteomyelitis).

AHA Coding Clinic – Guidance on coding diabetes with osteomyelitis using E11.69 + M86.-.

Explanation:
For a condition to be captured as an HCC for risk adjustment, it must be specifically documented and actively managed, evaluated, or addressed during the encounter. In this scenario, the patient has Type 2 diabetes with peripheral neuropathy (a chronic complication), COPD without exacerbation, and stable depression. The diabetes with chronic complications (HCC 18) and COPD (HCC 111) are documented and relevant; however, the depression is documented as "stable" but not specifically addressed or managed, so it should not be captured.

Correct Option:

B. HCC 18 and HCC 111

This is correct.

HCC 18 (Diabetes with Chronic Complications) : The patient has Type 2 diabetes with peripheral neuropathy, a chronic complication of diabetes. This qualifies for HCC 18.

HCC 111 (Chronic Obstructive Pulmonary Disease) : The patient has COPD, which is documented as having no recent exacerbations but is still a chronic condition relevant to the encounter.

HCC 58 (Major Depressive, Bipolar and Paranoid Disorders) is not captured because depression is documented as "stable" but is not addressed, evaluated, or managed during this visit.

Incorrect Options:

A. HCC 19, HCC 58, and HCC 111

This is incorrect because:

HCC 19 (Diabetes without Complications) is not assigned when a chronic complication (peripheral neuropathy) is documented. The diabetes is with complications, so HCC 18 applies.

HCC 58 (Depression) is not captured because it is only listed as stable and not evaluated or managed.

C. HCC 17 and HCC 58

This is incorrect because:

HCC 17 (Diabetes with Acute Complications) is not applicable—there is no acute complication like ketoacidosis or hyperosmolar state documented.

HCC 58 (Depression) is not captured as it is not addressed.

D. HCC 18, HCC 19, and HCC 111

This is incorrect because:

Both HCC 18 and HCC 19 cannot be assigned for the same condition. When diabetes has chronic complications, HCC 18 applies, and HCC 19 (without complications) is not coded. They are mutually exclusive categories.

Reference:

CMS-HCC Risk Adjustment Model – HCC 18 captures diabetes with chronic complications; HCC 19 is for diabetes without complications; only one applies.

ICD-10-CM Official Guidelines – Peripheral neuropathy is a chronic complication of diabetes (E11.42), mapping to HCC 18.

CMS-HCC Model – HCC 111 captures COPD.

ICD-10-CM Guidelines – Stable conditions that are not addressed during the encounter should not be coded for outpatient visits (Section IV.A).

ACDIS/AHIMA "CDI and Risk Adjustment" – Only diagnoses that are evaluated, treated, or otherwise managed during the encounter should be captured for HCCs.

Explanation:
The clinical scenario shows a significant drop in hemoglobin (from 10.4 to 8.6 g/dL) following a total hip replacement, with the provider starting iron supplementation (FeSO4) for fatigue and lethargy. However, the provider has not documented a specific diagnosis linking the anemia to the procedure or its cause (e.g., acute blood loss anemia, iron deficiency anemia, or postoperative anemia). The most appropriate action is to query the provider to clarify the diagnosis being treated.

Correct Option:

C. Query the provider for a diagnosis related to fatigue, decreased Hgb, and FeSO4.
This is correct. The patient has a significant drop in hemoglobin post-surgery, and the provider has prescribed iron therapy, which strongly suggests anemia is being treated. However, the provider has not documented a definitive diagnosis (e.g., acute posthemorrhagic anemia, iron deficiency anemia). A compliant query should present the clinical indicators (fatigue, lethargy, decreased Hgb, FeSO4 prescription) and ask the provider to clarify the specific diagnosis being managed. This ensures accurate coding and reflects the patient's true clinical condition.

Incorrect Options:

A. Instruct the provider to add iron deficiency anemia to the problem list.
This is incorrect. The CDI specialist cannot instruct or direct the provider to add a specific diagnosis. The provider must use clinical judgment to determine the diagnosis. Instructing the provider to add a specific diagnosis is leading and non-compliant. The appropriate action is to query with clinical indicators, not to direct the provider.

B. Review the lab work referenced by the provider in the progress note for congruence.
This is incorrect. While reviewing lab work is part of the CDI role, the issue here is the absence of a documented diagnosis. Simply reviewing the lab values does not address the documentation gap. The provider has not documented a diagnosis for the anemia, so the CDI specialist must query for clarification, not just verify lab results.

D. Add acute blood loss anemia to the diagnoses reported on the claim.
This is incorrect. CDI specialists do not add diagnoses to claims—that is the role of certified coders. Additionally, the CDI specialist cannot assume a diagnosis (e.g., acute blood loss anemia) without provider documentation. This action would be outside the CDI scope and could lead to inaccurate coding.

Reference:

ACDIS/AHIMA "Guidelines for Achieving a Compliant Query Practice" – Queries are appropriate when documentation is incomplete, ambiguous, or conflicting; CDI specialists should present clinical indicators and ask providers to clarify the diagnosis.

ICD-10-CM Official Guidelines – Anemia codes require provider documentation of the specific type (e.g., acute blood loss anemia, iron deficiency anemia).

ACDIS/AHIMA – CDI specialists do not add diagnoses to claims; that is the coder's responsibility.

CDI best practices – Queries should be non-leading and based on clinical indicators, not assumptions or directives.

Explanation:
The documentation notes significant weight loss and decreased muscle mass over the past six months—both are clinical indicators that strongly suggest malnutrition (protein-calorie malnutrition or other nutritional deficiency). However, the provider has not explicitly documented a diagnosis of malnutrition. This is a significant clinical condition that impacts severity of illness, risk adjustment, and patient outcomes. The most appropriate query is to ask the provider to clarify whether malnutrition is present and, if so, its severity.

Correct Option:

D. Presence of malnutrition
This is correct. The clinical indicators—significant weight loss and decreased muscle mass—are hallmark signs of malnutrition. These findings, especially in a patient with osteoporosis and a pathological fracture, are clinically significant and should be documented. Querying the provider to evaluate and document the presence of malnutrition (and its severity) is appropriate, compliant, and has a meaningful impact on risk adjustment and patient care.

Incorrect Options:

A. Degree of muscle atrophy
This is incorrect. While "decreased muscle mass" is documented, ICD-10-CM does not have a specific code for "degree of muscle atrophy" that would be clinically actionable in this context. The more significant and specific condition suggested by the documentation is malnutrition, which encompasses both weight loss and muscle mass loss. Querying for muscle atrophy would not add significant value compared to malnutrition.

B. Acuity of the pathological fracture
This is incorrect. The documentation states a "history of pathological fracture," indicating it is a past event, not an acute issue. There is no indication that the fracture is currently being treated or is the reason for the visit. Querying for the acuity of a resolved condition would not be appropriate or impactful.

C. Type of osteoporosis
This is incorrect. While osteoporosis is documented, the specific type (primary, secondary, idiopathic) may not be necessary for risk adjustment in this context. The more immediate and clinically significant query opportunity is the undocumented malnutrition, which is suggested by the weight loss and muscle mass loss. Osteoporosis type is secondary to the malnutrition concern.

Reference:

ICD-10-CM Official Guidelines – Malnutrition codes (E43, E44.0, E44.1) require provider documentation of the diagnosis and severity.

ASPEN (American Society for Parenteral and Enteral Nutrition) – Clinical criteria for malnutrition include significant weight loss and decreased muscle mass.

ACDIS/AHIMA "Guidelines for Achieving a Compliant Query Practice" – Queries should be based on clinical indicators that suggest a documented condition; weight loss and muscle mass are indicators for malnutrition.

CMS-HCC Risk Adjustment Model – Malnutrition (HCC 23) is a reportable HCC that impacts risk scores.

CDI best practices – Query for clinically significant conditions that are suggested by the documentation but not explicitly stated by the provider.

Explanation:
The patient has an indwelling Foley catheter and presents with symptoms and lab findings consistent with a urinary tract infection (UTI). The presence of a catheter is a significant clinical factor that changes the diagnosis to catheter-associated urinary tract infection (CAUTI) —a more specific, higher-impact condition. The provider documented only "UTI," missing the catheter association, which is a key query opportunity to capture the correct ICD-10-CM code (T83.51XA, infection of indwelling urinary catheter) and reflect the true clinical complexity.

Correct Option:

B. UTI related to catheter
This is correct. The presence of an indwelling Foley catheter with a positive urine culture for E. coli and elevated WBC strongly suggests a catheter-associated UTI (CAUTI) . Querying the provider to clarify whether the UTI is related to the catheter captures a more specific diagnosis (T83.51XA + N39.0) that has clinical significance for patient safety, infection control, and risk adjustment. This is the most appropriate and impactful query opportunity.

Incorrect Options:

A. Etiology of BPH
This is incorrect. The patient has benign prostatic hyperplasia (BPH), but the documentation does not suggest any uncertainty about its cause. BPH is a chronic condition, and querying for its etiology would not add clinical or risk adjustment value. The acute issue is the UTI and its association with the catheter.

C. Etiology of low back pain
This is incorrect. Low back pain is a symptom, and the most likely cause in this context is the UTI (pyelonephritis) or musculoskeletal issues. However, the primary clinical concern is the UTI and catheter association. Querying for the etiology of low back pain would be less impactful and distract from the more significant catheter-related infection.

D. Leukocytosis
This is incorrect. Leukocytosis (elevated WBC) is a lab finding that supports the diagnosis of infection. It is not a condition that should be coded separately when the underlying diagnosis (UTI) is known. Coding leukocytosis (D72.819) in addition to UTI is generally not appropriate when the cause is identified. Querying for leukocytosis would not add value.

Reference:

ICD-10-CM Official Guidelines – Catheter-associated UTI is coded with T83.51XA (infection and inflammatory reaction due to indwelling urethral catheter) followed by N39.0 (UTI).

CDC/NHSN – CAUTI surveillance definitions require the presence of a catheter at the time of infection.

ACDIS/AHIMA "Guidelines for Achieving a Compliant Query Practice" – Queries should address clinically significant conditions that are suggested by clinical indicators but not explicitly documented.

ICD-10-CM Guidelines – Symptoms (e.g., leukocytosis, low back pain) are not coded when the underlying diagnosis is established.

CMS-HCC Risk Adjustment – CAUTI has clinical and infection control significance; specifying catheter association is important for quality reporting (e.g., CMS hospital-acquired condition measures).

Explanation:
In the CMS-HCC risk adjustment model, the RAF (Risk Adjustment Factor) score is calculated using demographic factors and individual HCC weights. However, disease interactions add additional weight to the risk score beyond the sum of individual HCCs. When certain combinations of conditions coexist (e.g., diabetes and heart failure), they predict higher healthcare costs than each condition alone, resulting in an interaction factor that increases the total RAF score.

Correct Option:

B. Disease interactions
This is correct. The CMS-HCC model includes disease interaction factors that add incremental weight when specific combinations of HCCs are present in the same patient. These interactions recognize that certain comorbidities, when coexisting, lead to significantly higher resource utilization and costs than the sum of their individual weights. For example, HCC 18 (Diabetes with Chronic Complications) + HCC 85 (Heart Failure) triggers an interaction adjustment that increases the RAF score.

Incorrect Options:

A. Hierarchies
This is incorrect. Hierarchies are used to ensure that when a patient has multiple HCCs within the same disease category, only the highest-weighted HCC is counted. This prevents double-counting of related conditions and reduces the total weight, rather than adding weight. Hierarchies do not add additional RAF weight.

C. Resource-based relative values
This is incorrect. Resource-based relative values (RBRVs) are used in the Medicare Physician Fee Schedule to determine reimbursement for physician services (e.g., CPT codes). They are not part of the CMS-HCC risk adjustment model and do not affect RAF scores.

D. Conversion factors
This is incorrect. Conversion factors are used in the Medicare Physician Fee Schedule to convert relative value units (RVUs) into dollar amounts for payment. They are not part of the CMS-HCC risk adjustment model and do not affect RAF scores.

Reference:

CMS-HCC Risk Adjustment Model – Disease interactions are included to account for increased costs when certain HCCs coexist.

CMS-HCC Model Documentation – Interaction factors are applied when specific HCC combinations are present (e.g., diabetes + CHF).

CMS-HCC Model – Hierarchies reduce weights by counting only the highest HCC within a disease group; they do not add weight.

CMS Physician Fee Schedule – RBRVs and conversion factors apply to physician payments, not risk adjustment.

ACDIS/AHIMA "CDI and Risk Adjustment" – Disease interactions are a key component of the CMS-HCC model that increases RAF scores for patients with multiple complex conditions.

Explanation:
The CMS-HCC (Centers for Medicare & Medicaid Services Hierarchical Condition Categories) risk adjustment model is designed to predict the relative expected healthcare costs for Medicare beneficiaries. By using demographic factors and diagnosis data, the model calculates a risk score that reflects the anticipated resource use for an individual, ensuring that Medicare Advantage plans are adequately compensated for enrollees with higher healthcare needs.

Correct Option:

A. an individual’s anticipated cost of care.
This is correct. The CMS-HCC model measures an individual's anticipated cost of care relative to the average Medicare beneficiary. The RAF score predicts the expected healthcare expenditures for that individual, allowing CMS to adjust capitation payments to plans based on the health status of their enrolled population.

Incorrect Options:

B. a beneficiary’s risk of mortality.
This is incorrect. The CMS-HCC model is designed to predict costs, not mortality. While severity of illness and mortality risk may correlate with higher costs, the model's primary purpose is to predict healthcare resource utilization and expenditures, not the likelihood of death.

C. group beneficiary costs.
This is incorrect. While aggregate RAF scores are used to adjust payments at the plan level, the core unit of measurement in the CMS-HCC model is the individual beneficiary. The model calculates an individual risk score, which is then summed across a plan's population to determine overall payment adjustments.

D. physician cost of care provision.
This is incorrect. The CMS-HCC model does not measure physician-level costs. It predicts the total healthcare costs for a beneficiary across all services, including inpatient, outpatient, and professional services. It is not a measure of physician-specific cost of care provision.

Reference:

CMS-HCC Risk Adjustment Model documentation – "The CMS-HCC model predicts the relative cost of care for each beneficiary."

CMS "Risk Adjustment" overview – The model calculates an individual risk score to predict expected costs.

Medicare Advantage Payment System – RAF scores reflect individual anticipated costs, not mortality or group costs.

ACDIS/AHIMA "CDI and Risk Adjustment" – CMS-HCC measures predicted healthcare resource use for an individual.

CMS-HCC Model – Mortality is not a component of the model; cost prediction is the primary objective.

Explanation:
The Medicare Advantage (MA) Risk Adjustment Data Validation (RADV) program is CMS's primary audit and oversight tool for the MA program . Its fundamental purpose is to serve as a responsible steward of public funds by ensuring the integrity and accuracy of risk-adjusted payments made to Medicare Advantage Organizations (MAOs) . During an audit, CMS confirms that submitted diagnosis codes are supported by the patient's medical record, and if unsupported, may collect overpayments .

Correct Option:

A. ensure risk-adjusted payment integrity and accuracy.
This is correct. The RADV program is designed to identify improper risk adjustment payments made to MAOs by validating that diagnoses submitted for payment are properly documented in the medical record . This ensures payments reflect the enrollee's true health status and protects the Medicare Trust Funds. Overpayments have been estimated at billions of dollars annually , and the program has been significantly expanded to address these payment integrity issues .

Incorrect Options:

B. verify medical necessity of care provided.
This is incorrect. While RADV audits review medical records, they do so to validate specific diagnosis codes used for risk adjustment, not to determine whether the care provided was medically necessary. Medical necessity is a separate compliance concern addressed in other audits, such as those conducted by Recovery Audit Contractors (RACs) .

C. identify over-payments rendered to individual physicians.
This is incorrect. RADV audits target Medicare Advantage Organizations (MAOs) —the health plans—not individual physicians . However, MA plans may potentially pass financial liability to contracted providers through clawback clauses in their contracts .

D. support accuracy of Evaluation and Management billing.
This is incorrect. While evaluation and management (E/M) documentation may be reviewed during RADV audits, the program's scope is specific to diagnosis codes used for risk adjustment and HCC mapping . It does not validate the accuracy of E/M service billing or coding.

Reference:
CMS.gov RADV Program Overview; CMS.gov Final Rule on MA RADV; HHS.gov RADV Guidance; DLA Piper Analysis of RADV Final Rule; AHCA/NCAL RADV Update . *

Explanation:
A critical distinction between outpatient and inpatient coding is how uncertain diagnoses (e.g., "possible," "probable," "rule out," "suspected") are handled. In the outpatient setting, these diagnoses are not coded—only confirmed conditions are reported. In contrast, for inpatient stays, uncertain diagnoses may be coded as if they were established. This is a fundamental guideline that providers must understand for accurate outpatient documentation and coding.

Correct Option:

C. Documentation of uncertain diagnoses may not be assigned ICD-10-CM codes.
This is correct. In the outpatient setting, ICD-10-CM guidelines explicitly state that diagnoses documented as "probable," "suspected," "questionable," "rule out," or "working diagnosis" should not be coded. Only definitive diagnoses should be assigned. This is a key distinction from inpatient coding, where uncertain diagnoses are coded as if established. Providers must understand this to avoid expecting codes for suspected conditions that are not confirmed.

Incorrect Options:

A. Chronic conditions only have to be coded once a year even if relevant to multiple encounters.
This is incorrect. Chronic conditions should be coded each time they are evaluated, treated, or otherwise addressed during an encounter, not just once per year. If a chronic condition is relevant to multiple visits, it must be documented and coded for each relevant encounter.

B. First-listed diagnosis and principal diagnosis are synonymous terms.
This is incorrect. While both terms refer to the primary reason for the encounter/admission, they are setting-specific terms. "Principal diagnosis" is used for inpatient settings (defined as the condition chiefly responsible for the admission), while "first-listed diagnosis" is used for outpatient settings. They are not synonymous in application.

D. Documentation is only required for the main reason of the office visit.
This is incorrect. All diagnoses that are evaluated, treated, or otherwise managed during the office visit must be documented and coded. This includes chronic conditions that are addressed alongside the main reason for the visit. Documentation must support all coded conditions, not just the primary reason.

Reference:

ICD-10-CM Official Guidelines for Coding and Reporting – Section IV.A – Outpatient guidelines: "Do not code diagnoses documented as 'probable,' 'suspected,' 'questionable,' 'rule out,' or 'working diagnosis'."

ICD-10-CM Guidelines – Section IV.B – Outpatient visits should only report conditions that are documented as definitive.

ICD-10-CM Guidelines – Section II – Principal diagnosis is defined for inpatient; Section IV defines first-listed diagnosis for outpatient.

ICD-10-CM Guidelines – Section I.B.2 – All documented conditions that require or affect patient care, treatment, or management should be coded.

AHA Coding Clinic – Guidance on outpatient coding of uncertain diagnoses vs. inpatient coding rules.

Explanation:
The Medicare Shared Savings Program (MSSP) is a value-based care model that incentivizes healthcare providers to improve the quality of care for Medicare beneficiaries while reducing unnecessary costs . Its core goal is to encourage Accountable Care Organizations (ACOs) to work collaboratively to deliver coordinated, efficient care and, in return, share in a portion of the savings they generate for Medicare .

Correct Option:

B. Share in savings
This is correct. The primary objective and financial incentive of the MSSP is for ACOs to earn performance payments by sharing in the savings they achieve for the Medicare program . If an ACO successfully lowers healthcare costs while meeting quality benchmarks, it receives a bonus equal to a portion of those savings .

Incorrect Options:

A. Optimize risk score
This is incorrect. Optimizing risk scores is an objective of risk adjustment programs, not the overarching goal of the MSSP. The MSSP focuses on improving outcomes and reducing total cost of care, while a risk score is a metric used to predict costs, not to be optimized as a program goal.

C. Improve transitions of care
This is incorrect. While improving care coordination and transitions of care are important methods ACOs use to achieve savings , they are not the program's ultimate goal. They are strategies employed to achieve the primary goal of sharing in savings through cost reduction and quality improvement.

D. Increase fee schedule payment
This is incorrect. The MSSP is designed to move away from volume-based fee-for-service payments toward value-based payments. Instead of increasing fee schedule reimbursement, it incentivizes providers to earn shared savings by reducing unnecessary spending .

Reference:
CMS.gov MSSP Overview; HHS Shared Savings Program Guidance; Healthline MSSP Explanation; Weill Cornell Medicine MSSP Study.