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ACDIS CCDS-O Exam Syllabus Topics:

Topic	Details
Topic 1	Healthcare regulations, reimbursement, and documentation requirements related to the Official Guidelines for
Topic 2	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 3	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 4	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.
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	Coding and Reporting, the Outpatient Prospective Payment System (OPPS), and provider coding

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ACDIS Certified Clinical Documentation Specialist-Outpatient Sample Questions (Q116-Q121):

NEW QUESTION # 116
Which of the following illustrates an example of a compliant, prospective query?

A. "Dr.: Your patient has a past medical history of CHF noted in her problem list. A review of her medication list shows Lasix 20 mg QD. Please review this diagnosis for pertinence and relevance during her upcoming visit and specify the type and acuity of the CHF if the diagnosis is still being addressed."
B. "Dr.: Your patient was here for her Annual Wellness Visit. A review of her medication list shows a new order for Lasix 20mg QD. A review of your progress note from that visit notes 2+ pitting edema bilaterally and that the patient complains of shortness of breath at night requiring her to sleep on 2 pillows. Please add CHF to the problem list if this is the diagnosis you are treating with the Lasix."
C. "Dr.: Your patient has chronic diastolic heart failure documented in her problem list. Can you please add this diagnosis to your progress note from her office visit?"
D. "Dr.: Your patient was ordered an echocardiogram at her last visit. Can you please document that the CHF was addressed as the basis for the study?"

Answer: A

Explanation:
A compliant prospective query is initiated before the next encounter so the provider can clarify documentation during the upcoming visit, using clinically relevant indicators without directing a specific diagnosis. Option A does this appropriately: it references an existing CHF history and a supportive medication (Lasix), then asks the provider to confirm whether CHF is pertinent at the next visit and, if so, to specify type and acuity. This supports accurate outpatient reporting because heart failure coding requires specificity (systolic/diastolic/combined; acute/chronic/acute on chronic) and should reflect what is actually evaluated/managed at the encounter. Option B is retrospective and attempts to justify a prior test. Option C is leading because it asks the provider to "add" a diagnosis to a past note rather than clarify current clinical status. Option D is also retrospective and uses "please add CHF," which is leading and can be perceived as prompting. Therefore, A best demonstrates a compliant prospective query.

NEW QUESTION # 117
A CDI specialist manager is reviewing the productivity metrics of the outpatient team and notes that one of the CDI specialists has a high query rate and a good physician response, but a low physician agree rate compared to the rest of the team. This likely indicates which of the following?

A. The CDI specialist is writing leading queries.
B. The cases the CDI specialist is reviewing are more complex than other clinics.
C. The data is not stratified enough to show a true picture of the productivity.
D. The CDI specialist is creating poor quality queries.

Answer: D

Explanation:
A high query rate with a strong physician response rate shows the CDI specialist is generating many queries and providers are opening/responding to them. However, a consistently low agree rate indicates providers frequently select "disagree," "clinically undetermined," or otherwise do not validate the query's suggested clarification. In outpatient CDI program management, that pattern most often reflects query quality problems-for example, queries that are not well-supported by encounter-specific clinical indicators, queries that are vague or overly speculative, or queries that do not align with outpatient reportability standards (e.g., prompting for diagnoses not clearly monitored/evaluated/assessed/treated). While leading queries are a compliance concern, the more direct operational inference from "high volume + answered + not agreed with" is that the queries are not clinically compelling or are poorly constructed, resulting in frequent provider non-concurrence. Case complexity alone would not reliably drive low agree rates if the queries were appropriately targeted and evidence-based. Therefore, the most likely interpretation is poor-quality queries requiring coaching on clinical support, clarity, and compliant construction.

NEW QUESTION # 118
Which of the following conclusions can be drawn from the impact of a CDI program on Clinic A using the table below?

A. Treated a more complex population than any of the other clinics in 2023.
B. Consistently captured a higher RAF percentage each month in 2023 than in 2022.
C. Providers are more engaged in 2023 than in 2022.
D. Served a sicker population in 2023 than in 2022.

Answer: B

Explanation:
The only conclusion that is directly supported by the table is that Clinic A's percent RAF captured is higher in every month of 2023 compared with the corresponding month in 2022. The monthly values rise year-over-year (e.g., January 21% vs 17%, February 33% vs 25%, and continuing through December 84% vs 76%), showing a consistent improvement pattern across the entire calendar year. In outpatient CDI and risk adjustment work, "RAF capture" is commonly used as a performance indicator reflecting how completely documented and coded risk-adjusting conditions (e.g., HCC-supported diagnoses) are being captured within the measurement period. However, the table does not prove why the improvement occurred. It cannot confirm provider engagement (A) without workflow/participation data, cannot compare to other clinics (B) because no other clinic data are shown, and cannot establish that the population was sicker (C) because RAF capture measures documentation/coding completeness relative to opportunity, not inherent patient acuity. Therefore, D is the verified conclusion.

NEW QUESTION # 119
Calculate the expected yearly cost for this patient based on the RAF score.

A. $5,836.80
B. $12,672.00
C. $486.40
D. $17,011.20

Answer: A

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 × 0.608 = $486.40 per month. The question asks for the expected yearly cost, so convert PMPM to annual: $486.40 × 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 # 120
A patient presents to the clinic for follow up of type 2 diabetes. The patient is also noted to have peripheral neuropathy. The patient has COPD and is found to have no recent exacerbations. The patient also has a history of depression, reported as stable. Which of the following CMS-HCCs will be captured for this visit?
HCC 17: Diabetes with Acute Complications
HCC 18: Diabetes with Chronic Complications
HCC 19: Diabetes without Complications
HCC 58: Major Depressive, Bipolar and Paranoid Disorders
HCC 111: Chronic Obstructive Pulmonary Disease

A. HCC 17 and HCC 58
B. HCC 18, HCC 19, and HCC 111
C. HCC 19, HCC 58, and HCC 111
D. HCC 18 and HCC 111

Answer: D

Explanation:
In the CMS-HCC model, diabetes categories are hierarchical, meaning you capture the highest supported diabetes HCC for the year, not multiple diabetes HCCs simultaneously. Type 2 diabetes with peripheral neuropathy represents a chronic diabetic complication, so it maps to HCC 18 (Diabetes with Chronic Complications) rather than HCC 19 (without complications) or HCC 17 (acute complications). COPD is documented as present and clinically relevant (even without an exacerbation) and therefore maps to HCC 111 (Chronic Obstructive Pulmonary Disease) when it is assessed/managed as part of the visit. "History of depression, stable" does not necessarily meet the threshold for HCC 58, which is reserved for specific serious psychiatric diagnoses (e.g., major depressive disorder, bipolar disorder, paranoid disorders). A general "depression" history, especially if not specified as major depressive disorder and not actively addressed, often will not support HCC 58 capture. Therefore, the visit captures HCC 18 and HCC 111 only.

NEW QUESTION # 121
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