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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 |
| Exam Format: | Computer-based, Remotely proctored or test center delivery, Multiple-choice questions |
| Related Certifications: | Certified Clinical Documentation Specialist (CCDS) |
| Certificate Validity Period: | 2 years |
| Available Languages: | English |
| Passing Score: | 85 out of 120 scored questions |
| Real Exam Qty: | 140 (120 scored, 20 unscored) |
| Exam Price: | $280 (ACDIS members), $380 (non-members), +$100 international fee |
| 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 # 62
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: C
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 # 63
Which entity is tasked by CMS to process both Part A and Part B beneficiary claims?
Answer: C
Explanation:
CMS assigns Medicare Administrative Contractors (MACs) to administer Medicare fee-for-service operations at the jurisdictional level, including processing and paying both Part A and Part B claims. In outpatient CDI terms, MACs are central because they apply Medicare coverage rules, edit logic, and payment policies that determine whether documentation supports medical necessity and correct coding for submitted claims. This includes adjudicating hospital outpatient (Part B) services and facility-based Part A services, handling provider enrollment functions, issuing Local Coverage Determinations (as applicable through their medical review processes), and responding to claim inquiries and appeals routing. By contrast, Recovery Audit Contractors (RACs) focus on identifying and recovering improper payments (post-payment auditing). Risk Adjustment Data Validation (RADV) contractors validate diagnosis data submitted for risk-adjusted programs (primarily Medicare Advantage), not routine FFS claim processing. Zone Program Integrity Contractors (ZPICs) (and their successors in some contexts) focus on program integrity and fraud/waste/abuse investigations rather than standard claim adjudication. Therefore, the entity responsible for processing Part A and Part B beneficiary claims is the MAC.
NEW QUESTION # 64
The primary purpose of the RADV program is to
Answer: D
Explanation:
RADV (Risk Adjustment Data Validation) is a CMS audit program used in Medicare Advantage to confirm that diagnoses submitted for risk adjustment are supported by medical record documentation and meet reporting requirements. Its central aim is payment integrity-ensuring that risk-adjusted capitation payments to Medicare Advantage organizations are accurate based on valid, documented conditions. In outpatient CDI practice, RADV risk underscores why documentation must clearly support each reported diagnosis (e.g., condition evaluated/assessed/treated, clinically relevant, and properly documented by an eligible provider), because unsupported diagnoses can lead to payment recoupment and compliance exposure. RADV is not designed to assess medical necessity of the services provided (that is typically addressed through utilization review and other payer audits), nor is it focused on identifying overpayments to individual physicians (it targets plan-level risk adjustment payments). It also is separate from E/M leveling accuracy, which is governed by CPT/E/M guidelines and distinct audit processes. Therefore, the best definition of RADV's primary purpose is ensuring the integrity and accuracy of risk-adjusted payments.
NEW QUESTION # 65
Which of the following is a key component that is used to calculate Relative Value Units (RVUs)?
Answer: C
Explanation:
RVUs are the foundation of Medicare's physician fee schedule methodology and are built from three core components: physician work (wRVU), practice expense (peRVU), and malpractice (mpRVU). The malpractice expense RVU reflects the relative professional liability insurance cost associated with providing a service and is a defined element of the RVU calculation used to determine payment rates. In outpatient documentation and CDI education, it's important to distinguish what drives code selection versus what is a payment calculation ingredient. Time with the patient and medical decision making influence E/M code selection under current E/M rules, but they are not standalone components of the RVU formula itself-they contribute indirectly by determining which CPT code is billed, and each CPT code has preassigned RVUs. Physician specialty type also is not a direct RVU component, even though specialty patterns can affect typical service mix and overall wRVU productivity. Therefore, among the options, malpractice expense is the explicit RVU component used in the calculation.
NEW QUESTION # 66
CMS-HCCs are used to
Answer: B
Explanation:
The CMS-HCC model is a risk adjustment methodology used primarily to set capitated payments for Medicare Advantage (MA) organizations based on the expected cost of caring for their enrolled beneficiaries. Under this approach, CMS calculates a Risk Adjustment Factor (RAF) for each member using demographic variables (such as age/sex and certain entitlement factors) plus disease burden captured from ICD-10-CM diagnoses that map to Hierarchical Condition Categories (HCCs). The resulting RAF increases or decreases the plan's payment to better match predicted healthcare needs-higher RAF for sicker, more complex patients and lower RAF for healthier patients. ACDIS outpatient CDI education emphasizes that the purpose is not physician reimbursement based on a "principal diagnosis" (an inpatient concept) and not payment distribution tied directly to quality performance (that aligns more with MIPS/VBP frameworks). It also does not adjust capitation payments specifically "to physicians," nor does it exclude advanced practice providers in the way described. The correct use is to determine MA plan capitation payments through risk-adjusted member-level projections.
NEW QUESTION # 67
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