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| Certification Vendor: | ACDIS |
|---|---|
| Exam Name: | Certified Clinical Documentation Specialist-Outpatient (CCDS-O) Exam |
| Exam Number: | CCDS-O |
| Available Languages: | English |
| Certificate Validity Period: | 2 years |
| Exam Price: | $280 (ACDIS members), $380 (non-members), +$100 international fee |
| Exam Duration: | 150 minutes |
| Exam Format: | Remotely proctored or test center delivery, Computer-based, Multiple-choice questions |
| Related Certifications: | Certified Clinical Documentation Specialist (CCDS) |
| Real Exam Qty: | 140 (120 scored, 20 unscored) |
| Passing Score: | 85 out of 120 scored questions |
| 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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問題 #23
Progress note states: "Recent EGD identified severe hyperplasia, without obstruction. Follow-up today for Barrett's. Complains of chest pain, difficulty swallowing, 15-pound weight loss in last 12 weeks. Diagnoses-significant weight loss, cachexia, anorexia, Barrett's esophagus, and chest pain. Plan short term tube feeding-consult home health and dietitian for management." Which of the following diagnoses will trigger an HCC assignment?
答案:C
解題說明:
Within the CMS-HCC model, only certain diagnoses map to HCC categories that contribute to the RAF score. Among the listed options, cachexia is the diagnosis most likely to map to an HCC because it represents a serious systemic wasting condition associated with significant morbidity, higher expected resource use, and frequently coexists with advanced chronic disease. In contrast, Barrett's esophagus generally does not map to an HCC in CMS risk adjustment, and symptom-based diagnoses such as significant weight loss typically do not trigger HCC capture. Anorexia in general clinical usage often represents a symptom (loss of appetite) and, unless it is clearly documented as a qualifying malnutrition-related condition with appropriate specificity, it usually does not map to an HCC. The plan for tube feeding and dietitian involvement strengthens clinical relevance, but for risk adjustment the diagnosis must be one that maps to an HCC category-here, cachexia is the one that meets that criterion and would be the HCC-triggering diagnosis.
問題 #24
A patient presents with pulmonary rales, pulmonary edema found on chest x-ray, and bilateral ankle edema. Which of the following conditions will the provider MOST likely evaluate further?
答案:D
解題說明:
Pulmonary rales (crackles), radiographic pulmonary edema, and peripheral (ankle) edema together strongly suggest a systemic volume overload state, most classically due to heart failure. In ambulatory CDI chart review, these findings function as clinical indicators that drive the provider's diagnostic reasoning and typically prompt further evaluation of heart failure type and status (e.g., acute vs chronic, systolic vs diastolic, preserved vs reduced EF), along with assessment of severity and potential decompensation. Providers commonly correlate these indicators with additional data such as weight gain trends, BNP, echocardiogram findings, medication adherence (diuretics), and signs of congestion to determine whether the patient is experiencing a heart failure exacerbation requiring treatment adjustments. While pleural effusion may coexist and pneumonia can cause rales, the presence of pulmonary edema on chest x-ray plus bilateral ankle edema points more directly to a cardiac/volume etiology than an isolated infectious process. Pulmonary hypertension may contribute to dyspnea and edema but does not most directly explain pulmonary edema on imaging in the same way. Therefore, heart failure is the most likely condition to be evaluated further.
問題 #25
Along with history and examination, which of the following is considered a key component in reporting evaluation and management services?
答案:B
解題說明:
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.
問題 #26
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?
答案:C
解題說明:
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.
問題 #27
Which of the following is covered under the Outpatient Prospective Payment System (OPPS)? (Select all that apply)
答案:D
解題說明:
Under Medicare, OPPS is the payment system used primarily for hospital outpatient department (HOPD) services paid under APCs, and it also applies to a limited set of non-hospital entities for specific covered services. Community Mental Health Centers (CMHCs) are included under OPPS for certain outpatient mental health services, most notably partial hospitalization-type services that are paid using OPPS methodology, which is why CMHCs are considered "covered under OPPS" in many outpatient CDI education materials. In contrast, clinical diagnostic laboratory services are generally excluded from OPPS and paid under the Clinical Laboratory Fee Schedule (with separate billing and payment rules). Indian Health Services follow different statutory and payment structures and are not paid broadly under OPPS in the same way as HOPDs/CMHC OPPS services. Physical therapy reimbursement is typically governed by therapy-specific rules and fee schedule methodologies rather than being a standard OPPS-covered category in this context. Therefore, among the listed options, CMHCs are the correct OPPS-covered selection.
問題 #28
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