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ACDIS CCDS-O Exam Syllabus Topics:

Topic	Details
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.
Topic 4	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 5	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.

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ACDIS Certified Clinical Documentation Specialist-Outpatient Sample Questions (Q17-Q22):

NEW QUESTION # 17
A provider has been determined to be a high-cost provider after a total claims cost analysis. The provider's patient panel has an overall low HCC average score. Which of the following is the MOST likely explanation regarding the low HCC average score?

A. The provider is failing to capture all relevant diagnoses
B. The provider cares for patients of a higher acuity
C. The provider has a less complex patient population
D. The provider is not reporting unspecified diagnoses

Answer: A

Explanation:
In the CMS-HCC risk adjustment framework, the HCC average score reflects the coded burden of illness for the provider's attributed panel, driven by documented, reportable conditions that map to HCCs and qualifying demographic factors. If a provider appears "high cost" based on total claims but the panel's average HCC score is low, the most common CDI interpretation is documentation/coding under-capture: the clinical complexity driving utilization is not being fully documented and coded to HCC-relevant diagnoses. This creates a mismatch-actual resource use is high, but the recorded risk profile is artificially low-leading to unfavorable benchmarking because costs are compared against an expected spend that is too low for the true acuity. Option A would typically raise HCC scores, not lower them. Option C could explain both low HCC and low cost; it conflicts with the high-cost finding. Option D misunderstands HCC mechanics: "unspecified" does not reliably increase HCC capture and often reduces coding specificity/validity rather than improving risk adjustment. Therefore, incomplete capture of relevant diagnoses is the most likely driver.

NEW QUESTION # 18
Along with history and examination, which of the following is considered a key component in reporting evaluation and management services?

A. Review of systems
B. Nature of presenting problem
C. Medical decision making
D. Coordination of care

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 # 19
Which of the following is a leading query?

A. "The patient has a BMI of 42 per the nursing documentation. Does this patient have a medically relevant diagnosis to accompany the BMI? Please select one of the following options. A) morbid obesity, B) obesity, C) overweight, D) Other____, E) Clinically undetermined"
B. "The documentation includes modifications for current Celexa dosages. Can you please identify the condition treated with this medication?"
C. "The patient has a past medical history of RUL lung cancer. Should lung cancer be classified as: A) currently being treated, B) History of lung CA?"
D. "Your documentation states the patient drinks a 6-pack of beer nightly. Does this patient have alcohol dependence? Yes/No (circle one)"

Answer: D

Explanation:
A leading query is one that steers the provider toward a particular diagnosis or limits clinically appropriate choices in a way that can be perceived as prompting. Option D is leading because it presents a single, high-impact diagnosis ("alcohol dependence") and forces a binary yes/no response without offering reasonable alternative interpretations (e.g., alcohol use, alcohol abuse/harmful use, dependence in remission, or clinically undetermined) or an "other" option. In addition, it attempts to obtain a potentially new diagnosis based on one data point (quantity consumed) without a balanced set of diagnostic possibilities and supporting clinical indicators (tolerance, withdrawal, impairment, failed attempts to cut down, etc.). By contrast, A is open-ended and requests clarification of the treated condition; B provides two plausible classification choices (active vs history); and C offers multiple reasonable BMI-related diagnostic options plus "other" and "clinically undetermined," which supports compliant, non-leading clarification. Therefore, D best fits the definition of a leading query.

NEW QUESTION # 20
The majority of E/M services are based on which of the following criteria?

A. New/established, site of service, and level of service
B. New/established, level of service, and age of patient
C. New/established, physician specialty, and level of service
D. New/established, site of service, and time

Answer: A

Explanation:
In outpatient CDI and coding education, selecting the correct E/M code starts with identifying the encounter category (e.g., office/outpatient vs inpatient/observation vs ED) and whether the patient is new or established, because these define the applicable CPT code range. Next, the level of service is selected within that range based on the documentation supporting the required elements for that code family. For most E/M services, "site of service" (place/setting) and "new vs established" are foundational code-selection drivers, while "level" is determined by the record's support for the applicable leveling methodology (commonly medical decision making and, when allowed/appropriate, time). Time can be a valid leveling method for many office/outpatient E/M visits, but it is not universally the basis for the majority of E/M services across all categories; it is an alternative pathway when documentation supports it. Physician specialty and patient age do not define the majority of E/M code selection. Therefore, the best overall statement is new/established status + site of service + level of service.

NEW QUESTION # 21
Which of the following is the major difference between MIPS and APMs?

A. MIPS participation is required by eligible providers (non-participation results in a financial penalty), and APM participation is voluntary.
B. MIPS and APM participation is required of eligible providers.
C. MIPS and APM participation is voluntary by eligible providers.
D. APM participation is required by eligible providers (non-participation results in a financial penalty), and MIPS participation is voluntary.

Answer: A

Explanation:
MIPS (Merit-based Incentive Payment System) is the default Medicare Quality Payment Program pathway for most eligible clinicians who are not sufficiently participating in an Advanced APM. In practice, if a clinician is MIPS-eligible and does not meet reporting requirements (or performs poorly), Medicare applies a negative payment adjustment-so "non-participation" effectively carries financial risk. APMs (Alternative Payment Models), especially Advanced APMs, are not automatically required for all clinicians; they are model-based arrangements (often tied to specific payers, contracts, patient populations, and risk/quality terms) that clinicians typically enter through organizational participation decisions. A key operational difference emphasized in outpatient CDI education is that MIPS performance hinges on accurate, complete documentation supporting quality measures and resource use across a broad clinician population, whereas APM participation depends on being in a qualifying model and meeting its participation/threshold rules. Therefore, MIPS functions as the required/default track with potential penalties, while APM participation is elective and model-dependent.

NEW QUESTION # 22
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