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| Certification Vendor: | ACDIS |
|---|---|
| Exam Name: | Certified Clinical Documentation Specialist-Outpatient (CCDS-O) Exam |
| Exam Number: | CCDS-O |
| Exam Price: | $280 (ACDIS members), $380 (non-members), +$100 international fee |
| Related Certifications: | Certified Clinical Documentation Specialist (CCDS) |
| Passing Score: | 85 out of 120 scored questions |
| Exam Format: | Computer-based, Multiple-choice questions, Remotely proctored or test center delivery |
| Real Exam Qty: | 140 (120 scored, 20 unscored) |
| Exam Duration: | 150 minutes |
| Available Languages: | English |
| Certificate Validity Period: | 2 years |
| 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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NEW QUESTION # 133
A patient is seen by an endocrinologist to manage his poorly controlled diabetes with peripheral neuropathy and claudication. The patient has had several toes amputated in prior years and currently has a non-healing ulcer on the left foot. The patient's additional chronic conditions consist of the following: HF, CAD, COPD, history of prostate cancer, arthritis, depression, and sleep apnea. Which of the following chronic conditions should the CDI specialist consider for future education regarding RAF impact with the endocrinologist?
Answer: B
Explanation:
For RAF impact in the CMS-HCC model, the most valuable provider education targets are conditions that (1) map to HCCs or interact with HCC hierarchies, and (2) are clearly within the specialist's scope to assess and manage during visits. In this scenario, the endocrinologist is actively treating diabetes and its complications. Diabetes with peripheral neuropathy/vascular disease plus an active non-healing foot ulcer reflects significant diabetic disease burden and often supports additional required coding (e.g., diabetes complication code plus a separate site/severity ulcer code). The history of toe amputations is also important because amputation status can represent ongoing complexity, affects care planning (risk of recurrent ulcer/infection), and may contribute to risk capture depending on the model and associated complications. By contrast, CAD/COPD/HF may not be evaluated by the endocrinologist at the visit, "A1C" is a lab value (not a diagnosis), and "history of prostate cancer" generally does not risk-adjust like active malignancy. Therefore, educating on documenting diabetes, amputation status, and ulcer details best supports RAF accuracy.
NEW QUESTION # 134
Which of the following is designed to reduce claims denials and appeals by providing one-on-one feedback to the provider to increase accuracy in specific areas?
Answer: B
Explanation:
Targeted Probe and Educate (TPE) is an education-focused review initiative intended to improve billing accuracy and reduce future denials by combining targeted claim review with direct provider/supplier feedback. In outpatient CDI terms, TPE aligns with a "fix-forward" approach: auditors identify specific error patterns (often documentation, medical necessity, coding, or coverage rule issues), then provide one-on-one education so the provider can correct processes and documentation habits. This is distinct from Recovery Audit Contractors (RACs), which primarily identify and recoup improper payments, often after the fact, and are not structured as an individualized education cycle. The OIG Work Plan identifies oversight priorities and areas of potential fraud/waste/abuse; it does not deliver provider-level coaching to reduce denials. CERT measures Medicare improper payment rates through sampling and can drive policy/education broadly, but it is not designed as individualized, iterative provider education. Because TPE is specifically built around targeted review plus direct education to prevent repeat errors and reduce appeals, it is the best answer.
NEW QUESTION # 135
A patient presents for a right inguinal herniorrhaphy in ambulatory surgery and is placed in observation status postoperatively. Provider documentation states: "Observation related to the post procedural urinary retention likely related to benign prostatic hyperplasia or adverse reaction to anesthesia." From this documentation, which of the following is the first-listed diagnosis?
Answer: B
Explanation:
For outpatient/observation encounters, the first-listed diagnosis is the condition chiefly responsible for the services provided during that encounter. In this scenario, the patient's ambulatory surgery (herniorrhaphy) has already occurred, and the reason the patient is now in observation is explicitly documented as "post procedural urinary retention." That makes urinary retention the condition driving the extended monitoring, evaluation, and management in observation status. Benign prostatic hyperplasia and an adverse reaction to anesthesia are documented only as possible etiologies ("likely related to...or..."), and outpatient guidelines do not support coding uncertain diagnoses expressed as "likely" or as alternative possibilities without definitive confirmation. Therefore, those potential causes would not replace the confirmed problem that necessitated observation. The hernia was the reason for the procedure, but it is not the reason for the postoperative observation services described. Outpatient CDI practice reinforces documenting the clinical reason for observation and clearly distinguishing confirmed postoperative complications from suspected causes to support correct first-listed selection.
NEW QUESTION # 136
A patient presents to the clinic with indwelling Foley catheter, symptoms of fatigue, and low back pain with BPH. Labs reveal WBC 20, and the urine culture is positive for E. coli. Prescription antibiotics are ordered for a UTI. Which of the following is the BEST query opportunity?
Answer: A
Explanation:
The strongest CDI query opportunity is clarifying whether the UTI is catheter-associated. The patient has an indwelling Foley catheter, significant leukocytosis (WBC 20), a positive urine culture for E. coli, and is being treated with antibiotics for UTI-these indicators raise a clear question about the etiology of infection and whether it is related to the urinary catheter. In outpatient CDI practice, linking the infection to a device (when clinically supported) improves documentation accuracy, supports correct code assignment, and has important quality and compliance implications because catheter-associated UTIs are captured differently than uncomplicated UTIs. By comparison, querying the "etiology of BPH" is not supported as an immediate gap (BPH is already stated), and the "etiology of low back pain" is less directly tied to the documented treatment focus (UTI management). "Leukocytosis" is a lab finding that is already objectively supported and often represents a symptom/abnormal result rather than the principal clarification needed. Therefore, confirming whether the UTI is related to the Foley catheter is the best, most clinically anchored query.
NEW QUESTION # 137
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?
Answer: D
Explanation:
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.
NEW QUESTION # 138
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