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ACDIS CCDS-O Exam Syllabus Topics:

SectionObjectives
Topic 1: Disease Processes and Clinical Concepts- Anatomy and Physiology
  • 1. Pharmacology
  • 2. Pathophysiology
- Common Disease Categories
  • 1. Endocrine, Nutritional, and Metabolic Diseases
  • 2. Circulatory System
  • 3. Neoplasms
  • 4. Respiratory System
Topic 2: Healthcare Regulations and Reimbursement- Medicare OPPS Payment Logic
  • 1. APC Classification
  • 2. Status Indicators
- Risk Adjustment Models
  • 1. HCC (Hierarchical Condition Categories)
  • 2. RxHCC
Topic 3: Clinical Documentation Integrity (CDI) Program Operations- Provider Engagement and Education
  • 1. Feedback Mechanisms
- Query Process
  • 1. Compliance and Best Practices
  • 2. Query Types
Topic 4: Quality Initiatives- Patient Safety
- HEDIS Measures

>> CCDS-O學習筆記 <<

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最新的 Clinical Documentation Specialist CCDS-O 免費考試真題 (Q103-Q108):

問題 #103
A patient is seen in the office for a persistent cough. Provider documentation states: "History of chronic obstructive pulmonary disease, asthma, and hypertension. Hypertension treated with Enalapril. Cough an adverse effect of the ACE inhibitor; discontinue Enalapril. COPD stable. Instructed to continue meds for COPD/asthma." Which of the following diagnoses should be reported for this encounter?

答案:A

解題說明:
Outpatient diagnosis reporting requires coding conditions that are evaluated, assessed, treated, or that influence care/management at the encounter. The chief reason for the visit is the persistent cough, which is assessed and attributed to an adverse effect of an ACE inhibitor (enalapril). For outpatient coding of medication adverse effects, the documentation supports reporting both the manifestation (cough) and the adverse effect of the drug (ACE inhibitor adverse effect), because the provider identified the causal relationship and changed therapy by discontinuing enalapril. In addition, the provider addresses chronic conditions that are clinically relevant to the visit: COPD is assessed as "stable" and the patient is instructed to continue COPD/asthma medications, demonstrating ongoing management. Hypertension also remains relevant because medication therapy is adjusted due to the adverse effect; the patient still has HTN even though one agent is discontinued. Therefore, all five items-cough, ACE inhibitor adverse effect, COPD, asthma, and hypertension-are supported and should be reported, making option D the most appropriate.


問題 #104
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?

答案:D

解題說明:
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.


問題 #105
Symbicort is used to treat which of the following conditions?

答案:D

解題說明:
Symbicort is an inhaled combination medication containing an inhaled corticosteroid (ICS) and a long-acting beta-agonist (LABA). In outpatient chart review, this medication class is most strongly associated with chronic airway inflammatory diseases requiring controller therapy-especially persistent asthma (and also maintenance therapy for COPD, though COPD is not an option here). For CDI purposes, medication-to-diagnosis linkage can act as a clinical indicator supporting clarification when the visit note lists respiratory symptoms but does not clearly document the chronic condition being treated or its acuity/status. Symbicort is not used to treat musculoskeletal degenerative disease (osteoarthritis), peripheral nerve pain from diabetes (diabetic neuropathy), or cardiac pump failure (congestive heart failure). When Symbicort appears on the active med list, outpatient CDI commonly checks that the provider's documentation appropriately reflects asthma classification (intermittent vs persistent), current control, exacerbation status if applicable, and that the condition is being monitored/assessed/treated during the encounter to support reportability and accurate coding.


問題 #106
Which of the following health record elements impacts HHS-HCC risk scores?

答案:C

解題說明:
The HHS-HCC risk adjustment model (used for ACA Marketplace plans) calculates a member's risk score using a combination of demographic factors and diagnosis codes that map to HHS-HCCs. Among the listed health record elements, gender is a core demographic variable used in the model's coefficients because expected healthcare utilization and cost patterns differ by age/sex groupings. In outpatient CDI terms, this is why accurate demographic data capture (including sex) matters alongside complete and specific condition reporting. CPT codes do not drive HHS-HCC risk scores; the model relies on diagnosis reporting (ICD-10-CM) rather than procedure codes for risk category assignment. Discharge status is an encounter/billing element relevant to certain facility payment and quality measures, but it is not a standard HHS-HCC risk score input. Ethnicity is not used as a direct risk adjustment variable in the HHS-HCC model for score calculation. Therefore, gender is the correct element that impacts HHS-HCC risk scores.


問題 #107
A CDI specialist receives a call from a disgruntled provider regarding recent documentation queries. The provider claims to only have 15 minutes to see patients and does not have time for interruptions like this if it does not increase reimbursement. Which of the following is the BEST course of action to effectively facilitate communication?

答案:B

解題說明:
Effective outpatient CDI depends on provider engagement, efficient workflows, and respectful communication. When a provider is frustrated about time pressures, the most productive approach is to partner with them to reduce friction while preserving compliant documentation improvement. ACDIS outpatient CDI concepts emphasize collaboration and provider education-meeting the provider where they are, understanding their workflow constraints, and jointly designing a query process that is minimally disruptive (e.g., batching queries, aligning with clinic schedules, using prospective queries, leveraging templates, or routing through agreed channels). Option C directly addresses the root issue (workflow burden) and builds trust by seeking the provider's input and scheduling the discussion at their convenience. Option A is confrontational and frames CDI as a compliance demand rather than a clinical accuracy initiative. Option B is inappropriate because CDI cannot stop querying when clarification is needed for accurate documentation, coding, quality reporting, and risk adjustment. Option D escalates prematurely and damages relationships; escalation is typically reserved for persistent, unresolved non-responsiveness after collaborative efforts and leadership-supported education.


問題 #108
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