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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
Exam Format:Multiple-choice, Computer-based exam
Related Certifications:Certified Clinical Documentation Specialist (CCDS)
Real Exam Qty:140 questions (120 scored)
Passing Score:85 out of 120 scored questions
Available Languages:English
Recommended Training:ACDIS CCDS-O Exam Candidate Handbook (download via official site)
ACDIS Official Certification Resources
Exam Registration:ACDIS Certification Page
CCDS-O Certification Information
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 Exam Syllabus Topics:

TopicDetails
Topic 1
  • Coding and Reporting, the Outpatient Prospective Payment System (OPPS), and provider coding
Topic 2
  • 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.
Topic 3
  • 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.

ACDIS Certified Clinical Documentation Specialist-Outpatient Sample Questions (Q136-Q141):

NEW QUESTION # 136
Which of the following coding guidelines is MOST important for a provider to understand when selecting diagnosis codes for an office visit as opposed to an inpatient stay?

Answer: D

Explanation:
A core outpatient guideline difference is how to handle uncertainty in diagnoses. In the inpatient setting, facilities may code diagnoses documented as "probable," "suspected," "likely," or "rule out" at discharge if they meet inpatient reporting rules. In outpatient/office settings, however, uncertain conditions generally are not coded as established diagnoses because the encounter is often focused on evaluation rather than confirmed final diagnoses. Instead, outpatient coding relies on confirmed conditions and/or signs and symptoms when a definitive diagnosis has not been made. This is why outpatient CDI education emphasizes precise provider language: if the clinician is still evaluating, they should document the symptom/abnormal finding and the assessment plan; if the condition is confirmed, they should state it clearly and link it to evaluation/management performed. Options A, B, and D are incorrect because chronic conditions may need to be reported whenever they are assessed/managed, "first-listed" is an outpatient concept distinct from inpatient "principal," and documentation should support all clinically relevant conditions addressed, not only the chief complaint.


NEW QUESTION # 137
A female patient who underwent total hip replacement 2 weeks ago is in for a follow-up visit with her PCP. The visit note states: "Patient complains of fatigue and lethargy. Hgb on discharge was 10.4gm/dL - now is 8.6 gm/dL. Will start FeSO4 325mg po daily with food. Repeat H/H in 2 weeks. She has return visit with Ortho then." Which of the following is the BEST course of action for the CDI specialist?

Answer: A

Explanation:
Outpatient CDI practice supports accurate, provider-validated diagnoses; CDI should not "diagnose," direct the provider to add a specific condition, or independently add diagnoses to the claim. Here, the documentation shows clinical indicators (fatigue/lethargy and hemoglobin drop from 10.4 to 8.6) and a treatment plan (oral iron and repeat H/H), but the provider has not stated a definitive diagnosis such as postoperative anemia, iron deficiency anemia, acute blood loss anemia, or anemia due to chronic disease. The best CDI action is to issue a compliant query that summarizes the relevant indicators and treatment and asks the provider to document the appropriate diagnosis and etiology, if clinically supported, and to link it to the plan of care. Option A is inappropriate because it leads the provider toward a specific diagnosis. Option D is noncompliant because coding must follow documented provider diagnoses. Option B may be a reasonable internal check, but it does not resolve the documentation gap.


NEW QUESTION # 138
Along with history and examination, which of the following is considered a key component in reporting evaluation and management services?

Answer: C

Explanation:
For reporting Evaluation and Management (E/M) services, the longstanding "key components" framework recognizes history, examination, and medical decision making (MDM) as the core elements used to determine the appropriate E/M level when the service is not reported based on time. In outpatient CDI education aligned with ACDIS concepts, MDM is emphasized because it reflects the clinician's cognitive work and risk-based thinking: the complexity of problems addressed, the amount/complexity of data reviewed and analyzed (labs, imaging, external notes, independent interpretation), and the risk of complications and/or morbidity from additional testing or treatment. "Review of systems" is a sub-element of the history component, not a separate key component. "Nature of presenting problem" and "coordination of care" can be clinically relevant and may support medical necessity or time-based billing (when documented appropriately), but they are not one of the three key components that define E/M reporting structure. Therefore, the best answer is Medical decision making.


NEW QUESTION # 139
A CDI specialist reviews the record of a patient with a history of CHF and DM Type 2 who was seen in the clinic earlier that day for possible bronchitis, fever, congestion, dyspnea, and cough. A chest x-ray indicated LLL infiltrate, and a nebulizer treatment was administered while in the office. Levofloxacin and albuterol were prescribed. Which of the following is MOST appropriate to query?

Answer: A

Explanation:
The documented clinical picture and treatment plan better align with pneumonia than uncomplicated bronchitis, creating a clear documentation/coding consistency opportunity. A LLL infiltrate on chest x-ray is a classic clinical indicator for pneumonia, and prescribing levofloxacin supports treatment of a likely bacterial lower respiratory infection rather than routine viral bronchitis. The patient also has fever, dyspnea, cough, and required an in-office nebulizer treatment, all of which can accompany pneumonia and increase clinical significance. In outpatient CDI practice, the most appropriate query is the one that clarifies the provider's definitive diagnosis when objective findings and management suggest a more specific condition than what is stated (e.g., "possible bronchitis"). Querying for diabetic complications or heart failure specificity is not as directly supported by the encounter's indicators and treatment actions provided, and "acuity of bronchitis" is secondary if the true condition is pneumonia. Clarifying whether pneumonia is present ensures accurate reporting, medical necessity support, and appropriate risk/quality capture.


NEW QUESTION # 140
Which of the following BEST describes a Stage 3 pressure ulcer?

Answer: A

Explanation:
Stage 3 pressure ulcers are defined by full-thickness skin loss where the injury extends through the dermis and involves damage or necrosis of subcutaneous tissue. Clinically, the ulcer may present as a deep crater and can include undermining or tunneling, but the key boundary is that bone, tendon, and muscle are not exposed. That deeper involvement (exposed muscle/tendon/bone) is characteristic of Stage 4, making option C incorrect. Option D describes partial-thickness loss, which aligns with Stage 2 (epidermis/dermis involvement such as abrasion or blister). Option A reflects early skin changes that correspond more closely to Stage 1 (intact skin with non-blanchable erythema and possible localized edema/induration). In outpatient CDI chart review, accurately distinguishing Stage 3 from Stage 2 and Stage 4 is essential because staging drives severity capture, care planning (wound care interventions, debridement considerations), and quality reporting. Documentation should clearly support "full thickness," the tissue layers involved, and the absence of exposed bone/tendon/muscle.


NEW QUESTION # 141
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