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| Certification Vendor: | ACDIS |
|---|---|
| Exam Name: | Certified Clinical Documentation Specialist-Outpatient |
| Exam Number: | CCDS-O |
| Exam Format: | Multiple Choice, Scenario-Based Items, Application & Analysis |
| Available Languages: | English |
| Related Certifications: | CCDS |
| Sample Questions: | ACDIS CCDS-O Sample Questions |
| Exam Way: | Proctored at testing centers |
| Pre Condition: | Candidates must have a background in healthcare, coding, or clinical documentation. |
| Official Syllabus URL: | https://acdis.org/certifications/certified-clinical-documentation-specialist-outpatient |
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NEW QUESTION # 15
A CDI specialist has created the following query:
"Dear Dr., Based on the following clinical indicators: history of CVA and physical therapy ordered to address left sided weakness, please confirm a diagnosis of hemiplegia." What feedback should be given to the CDI specialist regarding the query?
Answer: B
Explanation:
This query is non-compliant because it is leading: it asks the provider to "confirm a diagnosis of hemiplegia," presenting only one targeted outcome rather than requesting clarification in a neutral, clinically appropriate way. ACDIS-aligned outpatient query practice requires queries to be compliant, non-leading, and supported by clinical indicators, typically offering multiple reasonable options (or an open-ended format) and allowing the provider to document the most accurate clinical impression. In this scenario, "history of CVA," "left-sided weakness," and "physical therapy ordered" could reflect several possibilities-such as hemiparesis, residual weakness, post-stroke deficits, deconditioning, or other neurologic impairment-so the query should ask the provider to clarify the nature and diagnosis of the deficit (and laterality), not to confirm a single diagnosis. Option A is incorrect because coding cannot assume hemiplegia without provider documentation. Option C is not the best feedback because indicators can justify clarification. Option D is unnecessary; MRI results are not required for a compliant outpatient query.
NEW QUESTION # 16
When evaluating a CDI specialist's performance, which of the following expectations is held to the same standard for both inpatient and outpatient initiatives?
Answer: D
Explanation:
Across both inpatient and outpatient CDI, the single expectation that must remain consistent is query compliance. While productivity targets, the types of query opportunities, and the way "impact" is measured can differ significantly by setting (e.g., DRG/CC-MCC focus in inpatient vs. HCC capture, specificity, and MEAT support in outpatient), the compliance framework for querying does not change. A compliant query must be clinically supported, non-leading, clearly written, and must allow the provider to independently determine the most accurate documentation based on the record. It should include relevant clinical indicators, present reasonable options (including "other"/"unable to determine" when appropriate), and avoid language that appears to request diagnoses for payment purposes. These principles protect documentation integrity, support defensible coding, and reduce audit risk regardless of whether the encounter is hospital-based or ambulatory. By contrast, "review productivity" and "revenue impact" vary widely by program design and setting, and "query opportunities" differ because inpatient vs. outpatient have different reportability rules and documentation drivers. Therefore, query compliance is the metric held to the same standard in both environments.
NEW QUESTION # 17
Which of the following is the MOST compliant provider query?
Answer: C
Explanation:
The most compliant query is the one that is clinically supported, non-leading, and focused on clarifying documentation for correct reporting and medical necessity-without directing the provider to "add" diagnoses or document conditions for payment purposes. Option A presents relevant clinical context (no GI symptoms; family history) and asks the provider to clarify whether the planned colonoscopy is screening or diagnostic, which is a legitimate documentation clarification affecting correct code selection and coverage rules. It does not imply a desired answer and does not instruct the provider to document additional diagnoses. Option B is problematic because it instructs the provider to "document these conditions" if treated, which can be perceived as prompting and is not tied to encounter-specific indicators. Option C is based primarily on historical information and asks a yes/no about remission, which can be leading and may not reflect current-visit evaluation. Option D effectively asks the provider to add a diagnosis based on nursing documentation, which risks leading language and requires provider confirmation and assessment. Therefore, A is most compliant.
NEW QUESTION # 18
Progress note states: "Recent EGD identified severe hyperplasia, without obstruction. Follow-up today for Barrett's. Complains of chest pain, difficulty swallowing, 15-pound weight loss in last 12 weeks. Diagnoses-significant weight loss, cachexia, anorexia, Barrett's esophagus, and chest pain. Plan short term tube feeding-consult home health and dietitian for management." Which of the following diagnoses will trigger an HCC assignment?
Answer: D
Explanation:
Within the CMS-HCC model, only certain diagnoses map to HCC categories that contribute to the RAF score. Among the listed options, cachexia is the diagnosis most likely to map to an HCC because it represents a serious systemic wasting condition associated with significant morbidity, higher expected resource use, and frequently coexists with advanced chronic disease. In contrast, Barrett's esophagus generally does not map to an HCC in CMS risk adjustment, and symptom-based diagnoses such as significant weight loss typically do not trigger HCC capture. Anorexia in general clinical usage often represents a symptom (loss of appetite) and, unless it is clearly documented as a qualifying malnutrition-related condition with appropriate specificity, it usually does not map to an HCC. The plan for tube feeding and dietitian involvement strengthens clinical relevance, but for risk adjustment the diagnosis must be one that maps to an HCC category-here, cachexia is the one that meets that criterion and would be the HCC-triggering diagnosis.
NEW QUESTION # 19
Provider documentation states: "Patient is here for follow-up for multiple chronic conditions, including COPD, HTN, DM, and alcohol abuse. She admits to drinking more than she has in the past, starting in the early morning and consumes at least a pint a day. Her BP today is elevated at 165/89. Discussed medications and diet. As she continues to be dependent on alcohol, several treatment options were offered. She stated she would think about it." Which of the following groups of diagnoses is supported by the clinical indicators described?
Answer: D
Explanation:
The clinical indicators strongly support alcohol dependence, not merely alcohol "use" or "abuse." The patient reports heavy, compulsive intake (early-morning drinking and at least a pint daily), and the provider explicitly documents that she "continues to be dependent on alcohol" and discusses treatment options-this aligns with a dependence-level disorder being addressed. Hypertension is also supported because the BP is elevated (165/89) and the provider documents management activity (medications and diet counseling), meeting encounter relevance/reportability expectations. Diabetes is listed among chronic conditions, but the scenario provides no indicators of complications (no neuropathy, CKD, ulcers, retinopathy, etc.), so the supported choice is DM type 2 without complications rather than "with complications." Although COPD is listed in the "including" statement, no COPD-specific assessment/monitoring/treatment is described in the indicators provided, so the best-supported grouped option focuses on the conditions with clear supporting indicators and management in the note: DM2 without complications, HTN, and alcohol dependence.
NEW QUESTION # 20
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