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ACDIS CCDS-O Exam Syllabus Topics:

TopicDetails
Topic 1
  • 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 2
  • Coding and Reporting, the Outpatient Prospective Payment System (OPPS), and provider coding
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
  • 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 5
  • 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 6
  • 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 (Q136-Q141):

NEW QUESTION # 136
A morbidly obese patient with a BMI of 45 who is reliant on CPAP at night is likely to have which of the following conditions?

Answer: A

Explanation:
Nightly reliance on CPAP in a morbidly obese patient most strongly points to sleep-disordered breathing, and in the context of severe obesity (BMI 45), it raises concern for obesity hypoventilation syndrome (OHS), which is characterized by alveolar hypoventilation (chronic hypoventilation with hypercapnia) that is not fully explained by other pulmonary or neuromuscular causes. While CPAP is commonly prescribed for obstructive sleep apnea, severe obesity increases the likelihood of associated hypoventilation physiology; in outpatient CDI review, this becomes a documentation opportunity to ensure the provider specifies whether the patient has OSA alone versus OSA with OHS/alveolar hypoventilation, because the latter reflects higher clinical complexity and requires clear monitoring/management (e.g., ABGs or bicarbonate trends, symptoms of hypoventilation, adherence, need for BiPAP). Heart failure and pulmonary edema are not implied by CPAP use, and essential hypertension is common in obesity but not the condition most specifically linked to CPAP dependence. Therefore, alveolar hypoventilation is the best supported answer.


NEW QUESTION # 137
Which of the following is a key component that is used to calculate Relative Value Units (RVUs)?

Answer: A

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 # 138
Upon retrospective review of a patient visit 2 weeks prior, a CDI specialist notes physician documentation stating the following: "Sick Sinus Syndrome in 2016 s/p pacemaker placement. Latest EKG shows normal paced rhythm." There are no codes noted for Sick Sinus Syndrome or the pacemaker. Which of the following is the BEST course of action for the CDI specialist?

Answer: D

Explanation:
In outpatient CDI, diagnoses reported for an encounter must be supported as current and clinically relevant to that visit (evaluated, monitored, assessed, treated, or otherwise affecting care). The note documents a history of sick sinus syndrome with pacemaker placement in 2016 and indicates the current rhythm is paced. The most clearly reportable, present condition is the presence of a cardiac pacemaker, which is a status that can affect clinical decision-making (e.g., interpretation of rhythm findings, medication choices, procedures, and future cardiac evaluation) and is appropriate to code when documented. However, the documentation does not show that sick sinus syndrome itself was actively assessed or managed during this visit; it is referenced as a past condition leading to the device. Because outpatient coding does not assume an active diagnosis solely from historical mention, the best action is to capture the pacemaker status code only. Retrospective amendment requests or rebilling steps are not the first-line CDI action when the documentation does not support active management of the underlying arrhythmia.


NEW QUESTION # 139
Calculate the expected yearly cost for this patient based on the RAF score.

Answer: C

Explanation:
In outpatient risk adjustment (commonly Medicare Advantage), the patient's predicted cost is derived from the Risk Adjustment Factor (RAF), which is the sum of component risk contributions. Here, the RAF is calculated by adding the HCC diagnoses score (0.166), disease interactions (0.112), and demographic score (0.330). That total equals 0.608. The PMPM (per-member-per-month) baseline cost is $800. To estimate the patient's expected monthly cost, multiply PMPM by RAF: $800 ร— 0.608 = $486.40 per month. The question asks for the expected yearly cost, so convert PMPM to annual: $486.40 ร— 12 = $5,836.80. ACDIS outpatient CDI teaching emphasizes that accurate documentation and compliant coding directly affect RAF through captured HCCs and interactions (when supported), which in turn drives expected resource needs and plan payment. Missing or unsupported diagnoses can understate RAF; vague documentation can prevent valid HCC capture.


NEW QUESTION # 140
A patient receives treatment for diabetes during a primary care visit. He has a glucose level of 240 and A1C of 7.9. The patient is prescribed Gabapentin 100mg TID. Which of the following should the CDI specialist query for?

Answer: C

Explanation:
In outpatient CDI chart review, a key skill is recognizing when medications and treatment plans suggest a specific diabetic complication that is not explicitly documented. Gabapentin is commonly prescribed for neuropathic pain, and in a diabetic patient it is frequently used to treat diabetic peripheral neuropathy symptoms (burning, tingling, numbness, shooting pain). ACDIS outpatient CDI guidance supports querying when there are strong clinical indicators that a more specific, clinically relevant diagnosis may be present and is being treated at the encounter, because diabetes codes require complication specificity when supported (e.g., "diabetes with neuropathy" rather than unspecified diabetes). The elevated glucose and A1C confirm ongoing diabetes management but do not, by themselves, indicate CKD, macular degeneration, or ketoacidosis. Ketoacidosis would require documentation of acute metabolic decompensation and supporting clinical/lab findings, which are not provided here. Therefore, the most appropriate clarification is whether the patient has diabetic peripheral neuropathy (and whether it is painful neuropathy) being managed with gabapentin, so the provider can document the condition clearly and accurately.


NEW QUESTION # 141
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