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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 |
| Real Exam Qty: | 140 (120 scored, 20 unscored) |
| Exam Format: | Remotely proctored or test center delivery, Computer-based, Multiple-choice questions |
| Certificate Validity Period: | 2 years |
| Exam Price: | $280 (ACDIS members), $380 (non-members), +$100 international fee |
| Available Languages: | English |
| Passing Score: | 85 out of 120 scored questions |
| Related Certifications: | Certified Clinical Documentation Specialist (CCDS) |
| 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 # 38
A patient is scheduled to see his PCP in 3 days. A CDI specialist notes that during the patient's last visit earlier this year, the problem list shows both DM 2 associated erectile dysfunction and DM 2 without complications. The last clinic note states that DM 2 with autonomic neuropathy was addressed. The CDI specialist should do which of the following FIRST?
Answer: B
Explanation:
The record contains conflicting documentation: the problem list includes both "type 2 diabetes without complications" and diabetes with complications (erectile dysfunction association), while the most recent clinic note indicates the provider addressed "DM2 with autonomic neuropathy," which is clearly a diabetic complication. In outpatient CDI, the first priority is to resolve internal inconsistency so coding accurately reflects the patient's current clinical status and what was evaluated/managed at the encounter. A query should therefore focus on whether the patient's diabetes is with complications (and which complications are active/being addressed) versus truly without complications, because "without complications" is generally not appropriate when neuropathy/other manifestations are present and being managed. CDI staff also should not unilaterally remove items from the provider-maintained problem list, and asking the patient is not a reliable documentation/coding source for establishing diagnoses. Once the provider clarifies diabetes complication status, a follow-up clarification can address specific linkages (e.g., erectile dysfunction due to diabetes) if needed for correct code assignment
NEW QUESTION # 39
E/M services must meet specific medical necessity criteria as defined by
Answer: A
Explanation:
For outpatient Evaluation and Management (E/M) services, "medical necessity" is ultimately judged against Medicare coverage policy, which is established through National Coverage Determinations (NCDs) and Local Coverage Determinations (LCDs). NCDs set nationwide rules for when specific services are considered reasonable and necessary, while LCDs are developed by Medicare Administrative Contractors to define coverage expectations within their jurisdictions, including indications, frequency limits, required documentation elements, and diagnosis-to-service relationships. Outpatient CDI and coding education emphasizes that correct E/M code selection and documentation must support not only the level of service (MDM/time) but also why the service was needed based on the patient's condition and the payer's coverage criteria. Specialty society recommendations and AMA/AHA guidance can inform clinical practice and coding conventions, but they do not define Medicare coverage requirements. Likewise, AHIMA provides professional guidance but does not set payer medical necessity policy. Therefore, the most accurate source defining medical necessity criteria for billing compliance is NCDs and LCDs.
NEW QUESTION # 40
In which of the following ways does payment determination (risk score calculation) differ between HHS-HCCs and CMS-HCCs?
Answer: B
Explanation:
A key ambulatory CDI distinction between the two major risk models is timing. The HHS-HCC model (used for ACA Marketplace risk adjustment) is commonly described as a concurrent model: it uses the enrollee's demographics and diagnoses from the same benefit year to reflect morbidity and support that year's risk transfer/payment balancing. In contrast, the CMS-HCC model (commonly applied in Medicare Advantage) is prospective: conditions documented and coded in the prior data collection year are used to predict expected cost for the following payment year. From an outpatient CDI perspective, this timing difference affects operational priorities. For CMS-HCC, accurate annual capture and recapture of active chronic conditions is essential because last year's documented conditions drive next year's risk score and revenue. For HHS-HCC, complete documentation and coding during the current year impacts the current year's risk measurement. Options referencing CPT codes are not correct for the core HCC risk score calculation, which is driven by demographics and ICD diagnosis reporting mapped to HCC categories.
NEW QUESTION # 41
Which of the following are appropriate clinical indicators to support a query related to alcohol dependency in remission?
Answer: C
Explanation:
To support a query for alcohol dependence in remission, outpatient CDI practice looks for indicators that reflect a documented history of dependence plus evidence the patient is actively maintaining sobriety or being followed for recovery status. Attendance at AA meetings together with a documented history of excessive alcohol use is a strong, direct indicator of recovery efforts and ongoing monitoring of a prior substance use disorder. This combination supports clarifying whether the provider intends to diagnose alcohol dependence in remission (versus current dependence, use without dependence, or no current disorder). By contrast, cirrhosis and elevated liver enzymes (option A) can be caused by many etiologies and do not, by themselves, establish dependence or remission status. Nausea, vomiting, and abdominal distention (option D) are nonspecific and may suggest acute illness or liver disease but are not specific to remission. Occasional social drinking with recreational drug use (option C) suggests current substance use and would not support "in remission" without additional documentation. Therefore, option B best supports a remission-related query.
NEW QUESTION # 42
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: B
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 # 43
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