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| Certification Vendor: | ACDIS |
|---|---|
| Exam Name: | Certified Clinical Documentation Specialist-Outpatient (CCDS-O) Exam |
| Exam Number: | CCDS-O |
| Exam Duration: | 150 minutes |
| Real Exam Qty: | 140 (120 scored, 20 unscored) |
| Available Languages: | English |
| Related Certifications: | Certified Clinical Documentation Specialist (CCDS) |
| Certificate Validity Period: | 2 years |
| Passing Score: | 85 out of 120 scored questions |
| Exam Format: | Multiple-choice questions, Remotely proctored or test center delivery, Computer-based |
| Exam Price: | $280 (ACDIS members), $380 (non-members), +$100 international fee |
| Recommended Training: | CCDS-O Official Study Guide CCDS-O Exam Candidate Handbook |
| Exam Registration: | Prometric Scheduling ACDIS Certification Application |
| 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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21. Frage
A patient with stage 3 CKD presents to the clinic for evaluation. Upon review of labs, an elevated iPTH and a normal phosphorus level are noted. Which of the following diagnoses may be appropriately queried based upon these lab values?
Antwort: B
Begründung:
In stage 3 chronic kidney disease, impaired vitamin D activation and early disturbances in calcium-phosphate regulation commonly drive a compensatory rise in parathyroid hormone (PTH), known as secondary hyperparathyroidism of renal origin. Outpatient CDI chart review looks for clinical indicators that suggest a condition being evaluated or requiring management, and an elevated iPTH in a CKD patient is a classic indicator that supports querying the provider for CKD-related mineral and bone disorder, specifically renal secondary hyperparathyroidism, if it is clinically being assessed/treated (e.g., monitoring trends, prescribing vitamin D analogs, calcimimetics, dietary counseling, nephrology follow-up). Primary hyperparathyroidism is less supported here because it typically requires a different biochemical pattern and clinical context (often hypercalcemia) rather than being driven by CKD physiology. Hypoparathyroidism is the opposite process (low PTH), making option C inconsistent with the lab finding. Option D is not supported because phosphorus is normal, not low, and hypophosphatemia is not documented as a driver. Therefore, querying for renal secondary hyperparathyroidism is most appropriate.
22. Frage
Which of the following therapies is MOST likely to be recommended?
Antwort: D
Begründung:
Metoprolol is a beta-blocker commonly used in atrial fibrillation to achieve ventricular rate control, reduce symptoms (palpitations, dyspnea), and improve hemodynamic stability, especially when the rhythm is persistent or recurrent. From an outpatient CDI chart-review perspective, therapy-to-diagnosis consistency is a key clinical indicator that supports clarifying the condition being treated and ensuring it is documented as assessed/managed at the encounter. The other options are clinically mismatched: "Ensure" is a nutritional supplement typically used for inadequate intake or weight loss and would not be recommended for morbid obesity; rivaroxaban (Xarelto) is an anticoagulant and would be inappropriate in the setting of hematemesis (active GI bleeding) where anticoagulation generally increases risk and would typically be held or reassessed; tamoxifen is an endocrine therapy for hormone receptor-positive breast cancer risk/treatment and is not a standard therapy for chronic congestive heart failure. Therefore, metoprolol for atrial fibrillation is the most appropriate and likely recommendation among the choices.
23. Frage
A 67-year-old male patient has been seen by a PCP multiple times this year. Diagnoses reported are diabetes with nephropathy with an HCC weight of 0.166; diabetes with retinopathy with an HCC weight of 0.166; atrial fibrillation with an HCC weight of 0.299, and a demographic risk factor weight of 0.332. Which of the following is this patient's final RAF score for these diagnoses?
Antwort: A
Begründung:
The patient's RAF is calculated by adding the applicable HCC weights plus the demographic factor, but only after applying the HCC model's hierarchy rules. In outpatient risk adjustment education (as emphasized in ACDIS-based training), certain condition groups are hierarchical-meaning multiple related diagnoses in the same hierarchy do not "stack." Instead, only the highest-ranked HCC in that disease group contributes to the RAF. Here, "diabetes with nephropathy" and "diabetes with retinopathy" both carry the same HCC weight (0.166) and fall within the diabetes complication hierarchy, so they do not add together; only one 0.166 value is counted. Atrial fibrillation contributes separately (0.299), and the demographic risk factor contributes (0.332). Therefore, the final RAF is 0.166 + 0.299 + 0.332 = 0.797. This illustrates why outpatient CDI focuses on documenting all clinically supported conditions for care accuracy, while understanding that some related diagnoses won't increase RAF beyond the highest applicable HCC in that hierarchy.
24. Frage
Which of the following statements is true regarding RADV reviews?
Antwort: A
Begründung:
RADV (Risk Adjustment Data Validation) is an audit process used to validate that risk-adjusting diagnoses submitted for payment are supported by compliant medical record documentation. A foundational requirement is that the record is properly authenticated by an acceptable provider-meaning the documentation must be attributable to the treating clinician through a valid signature. In compliant documentation standards emphasized in outpatient CDI education, acceptable authentication may be a traditional hand-written signature or an electronic signature/attestation that meets organizational and regulatory policy. Option B is not correct because diagnoses do not have to appear only on a facesheet or "final diagnosis" list; they may be supported within the body of the note (assessment/plan, problem-based charting, or other authenticated sections) as long as they are clearly documented and clinically supported. Options A and D are not reliably true statements in a general RADV context because RADV focuses on diagnoses supported by appropriate provider documentation and acceptable encounter record criteria; "technician-assigned" diagnoses are not acceptable, and radiology documentation alone may not meet all validation expectations depending on the program's rules and encounter context.
25. Frage
Which of the following adds weight to the risk score over and above the CMS-HCC weights for individual conditions?
Antwort: C
Begründung:
CMS-HCC risk adjustment assigns a baseline coefficient (weight) to each qualifying HCC condition, but certain combinations of conditions can increase predicted cost beyond what would be expected by simply adding the two individual weights. These added increments are captured through disease interaction factors, which apply when specific conditions coexist (for example, diabetes with certain severe complications, or other paired conditions defined by the model). In outpatient CDI, this is why documentation must clearly support both diagnoses-each must be clinically evaluated/managed and meet reporting rules-because accurately capturing the interacting conditions can legitimately increase the beneficiary's risk score. By contrast, hierarchies are designed to prevent double-counting within related condition families (the more severe manifestation typically supersedes a less severe one), which often limits-not adds-separate weights. Resource-based relative values and conversion factors belong to physician fee schedule payment methodology for services/procedures (RVUs and payment conversion), not HCC risk score calculation. Therefore, disease interactions are the correct concept that adds risk score weight beyond individual HCC coefficients.
26. Frage
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CCDS-O Unterlage: https://www.zertpruefung.ch/CCDS-O_exam.html
P.S. Kostenlose und neue CCDS-O Prüfungsfragen sind auf Google Drive freigegeben von ZertPruefung verfügbar: https://drive.google.com/open?id=1CjzPNy4QiwhqIvnUo7rGGpKlixLmMtsR