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ACDIS CCDS-O Exam Overview:

Certification Vendor:ACDIS (Association of Clinical Documentation Integrity Specialists)
Exam Name:ACDIS Certified Clinical Documentation Specialist โ€“ Outpatient (CCDS-O) Examination
Exam Number:CCDS-O
Exam Format:Multiple-choice, Computer-based exam
Real Exam Qty:140 questions (120 scored)
Passing Score:85 out of 120 scored questions
Available Languages:English
Related Certifications:Certified Clinical Documentation Specialist (CCDS)
Recommended Training:ACDIS CCDS-O Exam Candidate Handbook (download via official site)
ACDIS Official Certification Resources
Exam Registration:ACDIS Certification Page
CCDS-O Certification Information
Sample Questions:ACDIS CCDS-O Sample Questions
Exam Way:Computer-based testing via Prometric test centers or remote proctoring (ProProctor).
Pre Condition:Must meet education and experience requirements (e.g., RN, MD, DO, or HIM/coding credential such as RHIA, RHIT, CCS, CPC, CRC, COC) plus approximately 1โ€“2 years of outpatient clinical documentation experience using U.S. reimbursement systems.
Official Syllabus URL:https://acdis.org/certification/ccds-o

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ACDIS CCDS-O Exam Syllabus Topics:

TopicDetails
Topic 1
  • 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 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
  • Coding and Reporting, the Outpatient Prospective Payment System (OPPS), and provider coding

ACDIS Certified Clinical Documentation Specialist-Outpatient Sample Questions (Q115-Q120):

NEW QUESTION # 115
Which of the following are appropriate clinical indicators to support a query related to alcohol dependency in remission?

Answer: D

Explanation:
To support a query for alcohol dependence in remission, outpatient CDI practice looks for indicators that reflect a documented history of dependence plus evidence the patient is actively maintaining sobriety or being followed for recovery status. Attendance at AA meetings together with a documented history of excessive alcohol use is a strong, direct indicator of recovery efforts and ongoing monitoring of a prior substance use disorder. This combination supports clarifying whether the provider intends to diagnose alcohol dependence in remission (versus current dependence, use without dependence, or no current disorder). By contrast, cirrhosis and elevated liver enzymes (option A) can be caused by many etiologies and do not, by themselves, establish dependence or remission status. Nausea, vomiting, and abdominal distention (option D) are nonspecific and may suggest acute illness or liver disease but are not specific to remission. Occasional social drinking with recreational drug use (option C) suggests current substance use and would not support "in remission" without additional documentation. Therefore, option B best supports a remission-related query.


NEW QUESTION # 116
A CDI specialist has created the following query:
"Dear Dr., Based on the following clinical indicators: history of CVA and physical therapy ordered to address left sided weakness, please confirm a diagnosis of hemiplegia." What feedback should be given to the CDI specialist regarding the query?

Answer: C

Explanation:
This query is non-compliant because it is leading: it asks the provider to "confirm a diagnosis of hemiplegia," presenting only one targeted outcome rather than requesting clarification in a neutral, clinically appropriate way. ACDIS-aligned outpatient query practice requires queries to be compliant, non-leading, and supported by clinical indicators, typically offering multiple reasonable options (or an open-ended format) and allowing the provider to document the most accurate clinical impression. In this scenario, "history of CVA," "left-sided weakness," and "physical therapy ordered" could reflect several possibilities-such as hemiparesis, residual weakness, post-stroke deficits, deconditioning, or other neurologic impairment-so the query should ask the provider to clarify the nature and diagnosis of the deficit (and laterality), not to confirm a single diagnosis. Option A is incorrect because coding cannot assume hemiplegia without provider documentation. Option C is not the best feedback because indicators can justify clarification. Option D is unnecessary; MRI results are not required for a compliant outpatient query.


NEW QUESTION # 117
A patient is evaluated in the primary care clinic for chest pain, slight shortness of breath, and mild nausea. Documentation includes an ECG and chest x-ray to rule out MI. Which of the following diagnoses are reportable?

Answer: C

Explanation:
In the outpatient/ambulatory setting, ICD-10-CM reporting rules applied in CDI education distinguish clearly between confirmed diagnoses and "uncertain" or "rule out" conditions. Terms such as "rule out," "suspected," or "probable" generally are not coded as established diagnoses in the outpatient record because the encounter is often for evaluation and testing rather than definitive confirmation. Instead, coders report the patient's presenting signs and symptoms when a definitive condition has not been documented as confirmed by the provider. Here, the clinician ordered diagnostic testing (ECG and chest x-ray) specifically to rule out myocardial infarction (MI), but no final diagnosis of MI or angina is documented in the scenario. Therefore, "rule out MI" is not reportable, and neither is acute MI or angina unless explicitly diagnosed. The reportable conditions are the symptoms that drove the visit and required evaluation: chest pain (captured as "other chest pain" in the options), shortness of breath, and nausea.


NEW QUESTION # 118
When should the assignment of a not elsewhere classified (NEC)/other specified code be reported?

Answer: D

Explanation:
In outpatient CDI and ICD-10-CM coding guidance emphasized in ACDIS education, "NEC" (Not Elsewhere Classified) aligns with the "other specified" options in the code set and is used when the provider's documentation is clinically specific, but the classification system does not offer a unique code for that exact specificity. In other words, the record contains enough detail to describe a distinct type, cause, manifestation, or clinical variation of a condition, yet there is no more precise code available, so the "other specified" category appropriately captures that documented specificity. This is the opposite of "unspecified" (often associated with "NOS"), which is selected when the documentation is not detailed enough to choose a more specific code option. From a chart review perspective, NEC/other specified supports accurate reporting because it reflects that the clinician did document additional detail, and the coder is not defaulting to unspecified due to missing documentation-rather, the code set itself limits further granularity.


NEW QUESTION # 119
In February, a patient is diagnosed with prostate cancer, which is classified as HCC 23. In October, the patient is diagnosed with prostate cancer with bone metastases, which is classified as HCC 18. Which of the following is true about the patient's risk score?

Answer: A

Explanation:
In the CMS-HCC model, many related conditions are organized into hierarchies so that only the most severe manifestation within a disease family contributes to the RAF. This prevents double counting when multiple codes describe progressive severity of the same underlying condition. Cancer categories are a common example: a diagnosis reflecting metastatic disease represents substantially higher expected resource utilization than a diagnosis of localized/primary malignancy. In this scenario, the February prostate cancer maps to a lower-severity HCC (HCC 23), while the October documentation of prostate cancer with bone metastases maps to a higher-severity HCC (HCC 18). When both are captured within the applicable period, the hierarchy logic retains the higher-weighted metastatic category and suppresses the lower category. The timing of which was coded first does not control the hierarchy outcome, and both HCCs are not counted together when they fall within the same hierarchical grouping. Therefore, the patient's risk score calculation reflects HCC 18 rather than HCC 23.


NEW QUESTION # 120
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