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ACDIS CCDS-O Exam Syllabus Topics:

Topic	Details
Topic 1	and billing: Covers Official Coding Guidelines, OPPS reimbursement (APCs), and professional billing concepts including CPT E M codes and Medicare Physician Fee Schedule documentation.
Topic 2	Risk Adjustment Models and Impact of Documentation and Coding: Covers CMS-HCC model fundamentals, RAF scoring, Medicare Advantage payments, hierarchies, disease interactions, and compliant HCC reporting requirements.
Topic 3	Quality, Regulatory, and Health Initiatives: Covers population health, MSSP, ACO models, MACRA MIPS, compliant query development, RADV audits, OIG compliance, problem list maintenance, and HIPAA requirements in outpatient CDI.
Topic 4	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.

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ACDIS Certified Clinical Documentation Specialist-Outpatient Sample Questions (Q132-Q137):

NEW QUESTION # 132
If a patient is being seen for follow-up and the documentation indicates that the patient was admitted to the hospital 28 days ago with an acute cerebral infarction with remaining right-sided weakness, which of the following diagnoses would be MOST appropriate?

A. Hemiparesis following cerebral infarction affecting unspecified side
B. Other sequelae of cerebral infarction
C. Cerebral infarction, unspecified, hemiparesis affecting right dominant side
D. Hemiparesis following cerebral infarction affecting right dominant side

Answer: D

Explanation:
In the outpatient follow-up setting, when the acute stroke event has occurred in the recent past and the patient is now being evaluated for residual deficits, documentation and coding should focus on the sequelae (late effects) rather than re-coding the acute infarction itself-unless the provider clearly states the stroke is still in the acute phase and being actively treated as such. ACDIS outpatient CDI principles stress selecting the diagnosis that best reflects the reason for today's encounter and the condition being assessed/managed. Here, the ongoing clinical issue driving follow-up care is the persistent neurologic deficit (right-sided weakness/hemiparesis) after the cerebral infarction. Option C is the most specific and clinically accurate because it captures (1) the relationship to the prior cerebral infarction ("following cerebral infarction") and (2) laterality and dominance ("right dominant side"), which improves code specificity and reflects functional impact. Option A incorrectly keeps the focus on an unspecified cerebral infarction rather than the residual deficit, and option D is too nonspecific compared with a clearly described hemiparesis.

NEW QUESTION # 133
Which statement is MOST accurate about the problem list?

A. A well-maintained problem list is vital in the continuity of patient care.
B. More diagnoses on the problem list assist the provider in caring for the patient.
C. A CDI specialist should update the problem list to provide continuity of care.
D. Problem list diagnoses should be removed after one year.

Answer: A

Explanation:
A well-maintained problem list supports continuity of care by giving the care team an accurate, up-to-date clinical "snapshot" of active and relevant historical conditions that affect ongoing management, decision-making, and risk assessment. Outpatient CDI education emphasizes that the problem list should be curated-conditions should be current, clinically meaningful, and appropriately resolved or clarified (e.g., active vs history, controlled vs uncontrolled). Option A is incorrect because diagnoses are not removed based on an arbitrary time threshold; they are updated based on clinical status (resolved, inactive, erroneous, or no longer relevant). Option C is inaccurate because simply adding more diagnoses can introduce noise and increase the risk of outdated or incorrect conditions being propagated ("problem list bloat"), which can harm patient safety and lead to inaccurate coding. Option D is inaccurate because CDI professionals typically do not independently update the problem list; rather, they support providers through compliant queries, education, and process improvements so the treating provider validates and maintains the record. Therefore, B best reflects outpatient documentation best practice.

NEW QUESTION # 134
Which of the following is the MOST compliant provider query?

A. "According to a visit last year, this patient has a history of alcohol use; quit two years ago; previously drank 6-9 beers daily, 10-12 beers on weekend. Patient now attends AA meetings. Is the patient's alcohol use now in remission?"
B. "Noted that this patient is being referred for a colonoscopy. She has no documented GI symptoms and has a family history of colon cancer. When this patient is seen, please clarify whether this is a screening colonoscopy or diagnostic colonoscopy."
C. "Noted that the patient has skin that is 'warm and dry with no rashes or lesions'; however, nursing documentation describes a 'stage 3 sacral pressure ulcer' requiring wet-to-dry dressing changes. Please add the pressure ulcer to your ED assessment note if appropriate."
D. "The patient has a past medical history of CAD, HF, and COPD. Please document these conditions during the encounter today if they are still being treated."

Answer: B

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 # 135
Which of the following payment models enables Medicare to forecast costs for Medicare Advantage members for the coming year?

A. Relative Value Scale
B. Ambulatory Payment Classification
C. Geographic Practice Cost Indexes
D. Hierarchical Condition Categories

Answer: D

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 # 136
The primary purpose of clinical documentation improvement (CDI) is to:

A. Reduce coding workload
B. Ensure accurate and complete documentation reflecting patient severity and care provided
C. Increase hospital reimbursement
D. Simplify the physician's workflow

Answer: B

Explanation:
In outpatient CDI, the foundational aim is documentation integrity-making sure the medical record clearly and consistently tells the clinical story: why the patient is being seen, what conditions are evaluated/managed, the current severity and associated risks, what was done (assessment and treatment), and how this supports medical necessity and accurate code assignment. While reimbursement can be affected, it is an outcome-not the purpose. ACDIS-aligned CDI education emphasizes completeness and specificity so the record reflects true acuity and complexity (e.g., chronic conditions with current status, complicating comorbidities, medication management, and risk/decision-making). This improves downstream quality reporting, risk adjustment accuracy, continuity of care, and compliance because coders must code what is documented, not what is presumed. Strong CDI reduces denials and audit exposure by ensuring diagnoses are clinically supported (MEAT-monitor, evaluate, assess/address, treat) and linked to the encounter's work. In short, CDI exists to ensure the record accurately represents the patient's condition and the care delivered, enabling correct coding, quality measurement, and appropriate payment.

NEW QUESTION # 137
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