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| Certification Vendor: | ACDIS |
|---|---|
| Exam Name: | Certified Clinical Documentation Specialist-Outpatient (CCDS-O) Exam |
| Exam Number: | CCDS-O |
| Exam Duration: | 150 minutes |
| Certificate Validity Period: | 2 years |
| Related Certifications: | Certified Clinical Documentation Specialist (CCDS) |
| Exam Price: | $280 (ACDIS members), $380 (non-members), +$100 international fee |
| Real Exam Qty: | 140 (120 scored, 20 unscored) |
| Exam Format: | Multiple-choice questions, Computer-based, Remotely proctored or test center delivery |
| Passing Score: | 85 out of 120 scored questions |
| Available Languages: | English |
| Recommended Training: | CCDS-O Exam Candidate Handbook CCDS-O Official Study Guide |
| Exam Registration: | ACDIS Certification Application Prometric Scheduling |
| Sample Questions: | ACDIS CCDS-O Sample Questions |
| Exam Way: | Computer-based testing at Prometric centers or remote proctoring via ProProctor |
| Pre Condition: | RN, MD, DO, or HIM/coding certification (RHIA, RHIT, CCS, CPC, CRC, COC) + 2 years outpatient CDI experience; OR 1 year outpatient + 1 year inpatient CDI experience; minimum 2,000 hours per year |
| Official Syllabus URL: | https://acdis.org/certification/ccds-o |
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NEW QUESTION # 106
A 75-year-old with a PMH of chronic foot ulcer, CKD, and depression is seen by his PCP for continued fatigue and decreased urination. Labs drawn on previous day are reviewed. Patient describes extreme fatigue and no motivation. Assessment and plan include: "CKD 3 with renal failure - refer to nephrologist. Chronic nonpressure foot ulcer - home care for wound assessment. Depression - Rx for SSRI." Which of the following are the validated diagnoses that risk adjust and qualify as CMS-HCCs?
Answer: B
Explanation:
Under CMS-HCC methodology, risk adjustment is driven by ICD-10-CM diagnoses that map to HCC categories and are supported as active conditions addressed at the encounter. CKD stage 3 is a classic HCC-qualifying chronic condition because it represents ongoing kidney disease severity and expected resource use, and in this note it is actively assessed with labs reviewed and a nephrology referral. A chronic non-pressure foot ulcer is also typically HCC-qualifying when documented as ongoing and requiring management, which is supported here by home care/wound assessment planning. In contrast, "depression" (without specification such as major depressive disorder severity/status) commonly does not qualify for HCC in the way major depressive/bipolar categories do, making it less reliable as a risk-adjusting diagnosis. Likewise, "renal failure" is nonspecific and potentially conflicting with CKD stage 3; CDI best practice would be to clarify acuity/severity (acute kidney injury vs CKD stage vs ESRD) rather than assume "renal failure" as an HCC driver. Therefore, the validated HCC-qualifying pair is CKD 3 and chronic non-pressure ulcer.
NEW QUESTION # 107
Which of the following payment models enables Medicare to forecast costs for Medicare Advantage members for the coming year?
Answer: B
Explanation:
Medicare Advantage (MA) payments are risk adjusted so CMS can predict expected healthcare costs for each enrollee in the upcoming payment year. The model used for this forecasting is the CMS-HCC (Hierarchical Condition Category) risk adjustment methodology. It converts demographic factors (such as age/sex and eligibility status) plus documented, coded diagnoses (ICD-10-CM codes that map to HCCs) into a Risk Adjustment Factor (RAF). CMS then uses the RAF to adjust capitation payments to MA plans to reflect the member's anticipated resource needs. This is why outpatient CDI places heavy emphasis on accurate, specific capture and annual "recapture" of active chronic conditions that are monitored, evaluated, assessed/addressed, or treated during the encounter-because the prior year's valid HCCs drive the next year's predicted cost and payment. By contrast, APCs relate to OPPS facility outpatient payment, RVUs/RBRVS relate to physician fee schedule valuation, and GPCIs adjust payment geographically; none of those are the MA risk forecasting model.
NEW QUESTION # 108
A compliant physician query must:
Answer: D
Explanation:
A compliant query is designed to clarify the record without steering the provider to a predetermined answer. ACDIS-aligned standards stress two essentials: neutrality (non-leading phrasing) and clinical support (relevant indicators). Clinical indicators might include vitals, labs, imaging, medications, documented symptoms, problem list history, or assessment findings that create the need for clarification. The query should present the inconsistency or ambiguity, reference the supporting facts, and offer clinically reasonable answer choices including "other" and "unable to determine" when appropriate. This structure protects documentation integrity and reduces regulatory risk, because leading queries can be interpreted as directing documentation for payment rather than accuracy. Verbal-only queries are not sufficient when they affect coding; CDI programs typically require a documented query trail per policy. Purely open-ended questions without context are also problematic because they do not show why clarification is needed and may not be actionable. Proper non-leading, indicator-supported queries improve accuracy of diagnosis specificity, severity capture, and defensibility in audits while preserving provider autonomy.
NEW QUESTION # 109
Which component of the OPPS assigns payment rates based on procedure grouping?
Answer: D
Explanation:
Under the Medicare Outpatient Prospective Payment System (OPPS), hospital outpatient services are paid based on Ambulatory Payment Classifications (APCs). APCs are the mechanism that groups clinically similar services and procedures-typically identified through CPT/HCPCS reporting-into payment categories with established relative resource costs. CPT codes identify what service was performed, but CPT itself is not the OPPS payment grouping methodology; OPPS takes the coded line items and maps many of them into APC groupings (with packaging rules, status indicators, and modifier impacts) to determine the payment rate. DRGs are used for inpatient prospective payment and do not apply to OPPS outpatient claims in the same way. The Physician Fee Schedule applies to professional services (physician/clinician billing) rather than the hospital facility component paid under OPPS. From an outpatient CDI lens, accurate, specific documentation supports correct CPT/HCPCS selection, modifier use, units, and medical necessity linkages-ensuring services map to the correct APC and are not inappropriately bundled, denied, or downcoded during review. This protects payment accuracy and compliance by aligning the clinical story with the reported outpatient services.
NEW QUESTION # 110
Documentation states: "Patient with history of STEMI five weeks ago. Returning to office for follow-up. Problem list includes CAD, hypertension, heart failure, leukemia, malnutrition, and atrial fibrillation, all were relevant to the encounter. CBC and WBC reviewed and referred to oncologist. Follow-up with dietitian to further evaluate nutritional status." Which of the following is the MOST impactful risk adjusted query opportunity?
Answer: B
Explanation:
In outpatient risk adjustment, the highest-impact clarification is often the one that determines whether a condition is currently active (and therefore risk-adjustable) versus historical/resolved. "Leukemia" listed on the problem list, plus active review of CBC/WBC and referral to oncology, strongly suggests ongoing disease evaluation/management. ACDIS outpatient CDI principles emphasize querying to confirm whether the leukemia is active, in relapse, or in remission because that distinction can change code selection from an active malignancy to a history code, and history codes typically do not carry the same risk adjustment impact as an active HCC-bearing diagnosis. While heart failure type/acuity and malnutrition severity are also important for specificity and may affect risk capture, they generally represent refinement of already-established chronic conditions rather than a potential "on/off" determination of a major disease category. Likewise, atrial fibrillation subtype differentiation is clinically useful but usually does not materially change risk adjustment compared with confirming an active hematologic malignancy. Therefore, clarifying leukemia status/acuity is the most impactful risk-adjusted query opportunity.
NEW QUESTION # 111
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