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| Certification Vendor: | ACDIS |
|---|---|
| Exam Name: | Certified Clinical Documentation Specialist-Outpatient |
| Exam Number: | CCDS-O |
| Related Certifications: | CCDS |
| Exam Format: | Scenario-Based Items, Application & Analysis, Multiple Choice |
| Available Languages: | English |
| Sample Questions: | ACDIS CCDS-O Sample Questions |
| Exam Way: | Proctored at testing centers |
| Pre Condition: | Candidates must have a background in healthcare, coding, or clinical documentation. |
| Official Syllabus URL: | https://acdis.org/certifications/certified-clinical-documentation-specialist-outpatient |
>> CCDS-O Latest Test Questions <<
The ACDIS CCDS-O certification exam offers a great opportunity for ACDIS professionals to demonstrate their expertise and knowledge level. In return, they can become competitive and updated with the latest technologies and trends. To do this they just need to enroll in Certified Clinical Documentation Specialist-Outpatient (CCDS-O) certification exam and have to put all efforts and resources to pass this challenging CCDS-O exam. You should also keep in mind that to get success in the ACDIS CCDS-O exam is not an easy task.
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NEW QUESTION # 59
A patient is evaluated in the clinic. Documentation states: "HIV positive, gravida 1 at 24 weeks." Which of the following conditions will be coded and in which sequence based on the documentation?
Answer: A
Explanation:
In outpatient coding, selection and sequencing must follow ICD-10-CM Official Guidelines, including obstetric chapter rules. When HIV is documented in a pregnant patient, the pregnancy complication code is sequenced first because the pregnancy status frames the encounter and drives the obstetric complication coding structure. The phrase "HIV positive" (without documentation of HIV-related illness or "HIV disease") is treated as asymptomatic HIV infection status, which aligns with the status concept rather than active HIV disease. Therefore, the correct approach is to code pregnancy complicated by asymptomatic HIV first (obstetric complication category), followed by the HIV status code to fully describe the condition affecting the pregnancy. Options that place "pregnancy" second do not follow obstetric sequencing conventions, and options that assume "HIV disease" overstep the documentation because "HIV positive" alone does not confirm symptomatic HIV disease. Outpatient CDI best practice would be to query if the provider intends HIV disease versus asymptomatic status, but based strictly on the given statement, pregnancy with asymptomatic HIV is most appropriate.
NEW QUESTION # 60
Which of the following is covered under the Outpatient Prospective Payment System (OPPS)? (Select all that apply)
Answer: D
Explanation:
Under Medicare, OPPS is the payment system used primarily for hospital outpatient department (HOPD) services paid under APCs, and it also applies to a limited set of non-hospital entities for specific covered services. Community Mental Health Centers (CMHCs) are included under OPPS for certain outpatient mental health services, most notably partial hospitalization-type services that are paid using OPPS methodology, which is why CMHCs are considered "covered under OPPS" in many outpatient CDI education materials. In contrast, clinical diagnostic laboratory services are generally excluded from OPPS and paid under the Clinical Laboratory Fee Schedule (with separate billing and payment rules). Indian Health Services follow different statutory and payment structures and are not paid broadly under OPPS in the same way as HOPDs/CMHC OPPS services. Physical therapy reimbursement is typically governed by therapy-specific rules and fee schedule methodologies rather than being a standard OPPS-covered category in this context. Therefore, among the listed options, CMHCs are the correct OPPS-covered selection.
NEW QUESTION # 61
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?
Answer: B
Explanation:
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.
NEW QUESTION # 62
An established patient is defined as one who has received professional services from the same or another physician or qualified healthcare professional from the exact same specialty and sub-specialty and belongs to the same group practice, within the past how many years?
Answer: A
Explanation:
For outpatient E/M reporting, "new vs. established patient" status is determined using a lookback period based on prior professional services. An established patient is one who has received face-to-face (or other qualifying professional) services from the same physician or another physician/qualified healthcare professional of the same specialty and subspecialty in the same group practice within the previous three years. This definition is critical for compliant coding because it drives which E/M code family is available (new patient codes vs established patient codes), and it affects relative valuation, documentation expectations, and audit risk. Outpatient CDI education emphasizes helping providers document the medical necessity and complexity of the visit regardless of patient status, but also ensuring correct administrative classification so coders select the correct code set. The three-year window prevents inappropriate use of new patient codes when the patient has an ongoing clinical relationship with the practice/specialty, supporting accurate reimbursement and consistent reporting.
NEW QUESTION # 63
A CDI specialist is writing a query and including information from another facility's EHR via shared notes. Understanding that the ability to view shared notes may be revoked by the patient at any time, and to ensure HIPAA guidelines are followed, which of the following elements are BEST to include when sending the query?
Answer: C
Explanation:
When a CDI query references information from an externally shared note, best practice is to include enough identifying detail so the provider can locate and validate the source even if access is later revoked or if the shared record becomes unavailable. From an outpatient CDI and HIPAA-aligned workflow perspective, the query should clearly cite: where the information came from (the location of the shared note within the EHR/external record set), who authored it (provider name), when it was created (date of shared note), and the specific clinical documentation being referenced (the relevant statement/findings). This supports transparency, auditability, and minimizes the risk of misattribution or relying on inaccessible information. Options B-D are missing one or more critical elements-most notably the date and/or location of the shared note-making it harder to verify the source. Including "follow-up procedure" is not the priority for HIPAA-compliant source identification; the key need is traceability of the external documentation used to support the clarification request.
NEW QUESTION # 64
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