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ACDIS CCDS-O Exam Overview:

Certification Vendor:	ACDIS (Association of Clinical Documentation Integrity Specialists)
Exam Name:	ACDIS Certified Clinical Documentation Specialist – Outpatient (CCDS-O) Examination
Exam Number:	CCDS-O
Real Exam Qty:	140 questions (120 scored)
Passing Score:	85 out of 120 scored questions
Available Languages:	English
Exam Format:	Multiple-choice, Computer-based exam
Related Certifications:	Certified Clinical Documentation Specialist (CCDS)
Recommended Training:	ACDIS Official Certification Resources ACDIS CCDS-O Exam Candidate Handbook (download via official site)
Exam Registration:	CCDS-O Certification Information ACDIS Certification Page
Sample Questions:	ACDIS CCDS-O Sample Questions
Exam Way:	Computer-based testing via Prometric test centers or remote proctoring (ProProctor).
Pre Condition:	Must meet education and experience requirements (e.g., RN, MD, DO, or HIM/coding credential such as RHIA, RHIT, CCS, CPC, CRC, COC) plus approximately 1–2 years of outpatient clinical documentation experience using U.S. reimbursement systems.
Official Syllabus URL:	https://acdis.org/certification/ccds-o

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ACDIS CCDS-O 考試大綱：

主題	簡介
主題 1	Diseases and Disease Processes and Application to the Clinical Chart Review: Covers clinical indicators across all ICD-10-CM chapters, applied to chart reviews, with recognition of medications, diagnostic tests, and abbreviations as documentation clarification triggers.
主題 2	CDI Program Concepts: Department Metrics and Provider Education: Covers provider education development, CDI performance metrics including query rates, RAF progression, HCC capture, ACO MSSP impact, and physician documentation's effect on quality reporting.
主題 3	and billing: Covers Official Coding Guidelines, OPPS reimbursement (APCs), and professional billing concepts including CPT E M codes and Medicare Physician Fee Schedule documentation.
主題 4	Coding and Reporting, the Outpatient Prospective Payment System (OPPS), and provider coding

最新的 Clinical Documentation Specialist CCDS-O 免費考試真題 (Q45-Q50):

問題 #45
Which of the following section(s) of the Official Guidelines for Coding and Reporting are applicable to outpatient settings?

A. Section I, Conventions, General Coding Guidelines and Chapter Specific Guidelines; and Section IV, Diagnostic Coding and Reporting Guidelines for Outpatient Services
B. Section I, Conventions, General Coding Guidelines, and Chapter Specific Guidelines
C. Section III, Reporting Additional Diagnoses; and Section IV, Diagnostic Coding and Reporting Guidelines for Outpatient Services
D. Section IV, Diagnostic Coding and Reporting Guidelines for Outpatient Services

答案：A

解題說明：
In outpatient CDI and coding, the Official ICD-10-CM Guidelines that apply are the universal rules plus the outpatient-specific rules. Section I contains conventions, general coding guidelines, and chapter-specific guidance that govern code assignment in every setting (e.g., code structure, "use additional code," laterality, sequencing instructions, and condition-specific rules). Section IV is specifically written for outpatient services and drives core outpatient behaviors such as selecting the "first-listed" diagnosis based on the main reason for the encounter, reporting additional diagnoses that are evaluated/assessed/treated or impact care, and applying outpatient-only restrictions (for example, diagnoses documented as "rule out," "probable," or "suspected" generally are not coded in outpatient the way they may be for inpatient reporting). ACDIS outpatient CDI education emphasizes teaching providers to document clearly the reason for visit, the assessment/clinical relevance of each condition addressed, and the linkage between conditions and services rendered so Section I and Section IV rules can be applied accurately for compliant reimbursement and reporting.

問題 #46
Provider documentation states: "A 72-year-old patient with an active history of colon cancer, status post bowel resection, receiving chemotherapy. Newly diagnosed lung metastasis. Presents with UTI and elevated creatinine. Labs demonstrate a hemoglobin of 7.9, WBC of 2,500, and platelet count of 20,000." Which of the following is the query opportunity that supports a disease interaction that impacts the risk adjustment?

A. Colon cancer and lung metastasis
B. Colon cancer and chemotherapy
C. Chemotherapy induced pancytopenia
D. Acute tubular necrosis and UTI

答案：C

解題說明：
In outpatient risk adjustment, "disease interactions" refer to model coefficients that are triggered when certain clinically related conditions co-exist, reflecting higher expected resource use than either condition alone. In this case, the record already supports active malignancy care (colon cancer on chemotherapy) with newly documented metastasis, and the lab pattern (anemia, leukopenia, and severe thrombocytopenia) strongly suggests pancytopenia. The highest-yield query opportunity is to clarify whether the cytopenias represent chemotherapy-induced pancytopenia (or another specified etiology) because a confirmed, well-specified hematologic complication in the context of active cancer treatment is the type of combination that commonly drives interaction effects in risk models (cancer plus significant systemic complication/manifestation). Options A and B describe clinical context but do not, by themselves, establish an interaction-ready, separately reportable complication. Option C is unrelated to the presented lab-driven severity signal. Querying and documenting chemotherapy-induced pancytopenia supports accurate capture of severity and the interaction impact.

問題 #47
Which of the following is true of the RAF metric?

A. It is a relative measure of the probable costs to meet the healthcare needs of the individual beneficiary.
B. It is used to calculate each primary care office visit reimbursement based on documentation of chronic conditions.
C. It predicts how much the individual provider will be reimbursed for the concurrent practice year.
D. It is based only on demographic factors such as Medicaid status, gender, or aged/disabled.

答案：A

解題說明：
RAF (Risk Adjustment Factor) is a population risk stratification metric used in risk adjustment models to estimate expected healthcare resource utilization for an individual beneficiary relative to an average patient. In outpatient CDI, RAF is driven by a combination of demographic elements (such as age/sex and eligibility/status factors) and-critically-documented, coded conditions that map to risk categories (e.g., HCCs). The intent is not to "predict the provider's reimbursement" for the current year in a direct, visit-by-visit sense; rather, RAF contributes to actuarial projections of expected cost and supports payment benchmarking and budget setting in value-based arrangements (e.g., Medicare Advantage and certain shared savings models). RAF is also not based only on demographics (eliminating option B) and it does not determine reimbursement for each individual office visit (eliminating option D). ACDIS outpatient CDI emphasizes that accurate, specific documentation and coding of active, clinically supported conditions improves the accuracy of RAF, which in turn better aligns projected costs and comparisons across attributed populations.

問題 #48
In February, a patient is diagnosed with prostate cancer, which is classified as HCC 23. In October, the patient is diagnosed with prostate cancer with bone metastases, which is classified as HCC 18. Which of the following is true about the patient's risk score?

A. The risk score will be calculated based upon HCC 18 and HCC 23 because they were both documented and coded in the same calendar year.
B. The risk score will not be impacted by the presence of HCC 18 or HCC 23 because they are not currently being treated.
C. The risk score will be calculated based upon HCC 23 because it was captured first.
D. The risk score will be calculated based upon HCC 18 because it has the highest weight in the hierarchy HCC 23.

答案：D

解題說明：
In the CMS-HCC model, many related conditions are organized into hierarchies so that only the most severe manifestation within a disease family contributes to the RAF. This prevents double counting when multiple codes describe progressive severity of the same underlying condition. Cancer categories are a common example: a diagnosis reflecting metastatic disease represents substantially higher expected resource utilization than a diagnosis of localized/primary malignancy. In this scenario, the February prostate cancer maps to a lower-severity HCC (HCC 23), while the October documentation of prostate cancer with bone metastases maps to a higher-severity HCC (HCC 18). When both are captured within the applicable period, the hierarchy logic retains the higher-weighted metastatic category and suppresses the lower category. The timing of which was coded first does not control the hierarchy outcome, and both HCCs are not counted together when they fall within the same hierarchical grouping. Therefore, the patient's risk score calculation reflects HCC 18 rather than HCC 23.

問題 #49
Clinic documentation states: "Follow-up for post-induction chemotherapy for metastatic uterine cancer." To BEST identify the conditions being monitored and treated, a CDI specialist should

A. review the record for MRI results.
B. evaluate diagnostic lab results.
C. query for secondary sites.
D. clarify the morphology of the tumor.

答案：C

解題說明：
When documentation states "metastatic uterine cancer," the most important missing element for complete, accurate outpatient coding is where the cancer has metastasized (the secondary site[s]). In ambulatory CDI, identifying secondary sites best clarifies the full scope of disease being monitored and treated because metastatic disease coding relies on documenting both the primary malignancy and the specific metastatic location(s) (e.g., lung, liver, bone, peritoneum, lymph nodes). This supports correct severity representation, risk capture, treatment intent, and medical necessity for ongoing chemotherapy follow-up. While tumor morphology can be clinically relevant, it is usually established earlier in the diagnostic pathway and does not, by itself, define current metastatic burden. Likewise, reviewing labs or MRI results may provide supportive indicators, but they do not replace provider documentation of the confirmed metastatic sites being managed. A compliant query focused on secondary sites prompts the provider to document the current metastatic disease status (active, responding, progressing) and specific locations, which most directly identifies the conditions under treatment.

問題 #50
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