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| Certification Vendor: | ACDIS (Association of Clinical Documentation Integrity Specialists) |
|---|---|
| Exam Name: | ACDIS Certified Clinical Documentation Specialist – Outpatient (CCDS-O) Examination |
| Exam Number: | CCDS-O |
| Exam Format: | Multiple-choice, Computer-based exam |
| Available Languages: | English |
| Related Certifications: | Certified Clinical Documentation Specialist (CCDS) |
| Passing Score: | 85 out of 120 scored questions |
| Real Exam Qty: | 140 questions (120 scored) |
| Recommended Training: | ACDIS Official Certification Resources ACDIS CCDS-O Exam Candidate Handbook (download via official site) |
| Exam Registration: | CCDS-O Certification Information ACDIS Certification Page |
| 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 1–2 years of outpatient clinical documentation experience using U.S. reimbursement systems. |
| Official Syllabus URL: | https://acdis.org/certification/ccds-o |
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NEW QUESTION # 28
Which of the following conditions or findings supports a diagnosis of diabetes?
Answer: A
Explanation:
In outpatient clinical documentation and chart review, diabetes can be supported by recognized diagnostic thresholds. An HbA1c value reflects average blood glucose over approximately the prior 2-3 months and is commonly used to diagnose and monitor diabetes. An HbA1c ≥ 6.5% (when confirmed per clinical practice standards and interpreted in the appropriate clinical context) supports a diagnosis of diabetes; therefore an HbA1c of 7.0% clearly meets the threshold and supports diabetes. By comparison, a 2-hour OGTT value of 90 mg/dL is normal and does not support diabetes (diabetes is typically supported when the 2-hour value is ≥ 200 mg/dL). Hypoglycemia is low blood glucose and is not diagnostic of diabetes; it may occur in diabetics due to treatment but can also occur in non-diabetics for many reasons. A fasting glucose of 100 mg/dL is at most borderline/prediabetes range and does not meet diagnostic criteria for diabetes (diabetes is supported at ≥ 126 mg/dL).
NEW QUESTION # 29
Which of the following contributes to the risk adjustment score under the CMS-HCC model?
Answer: A
Explanation:
Under the CMS-HCC risk adjustment methodology, the RAF is calculated primarily from two categories of inputs: (1) demographic/enrollment eligibility factors and (2) diagnosis codes that map to HCCs based on documented, reportable conditions. Eligibility status matters because Medicare models differentiate beneficiaries by factors such as aged versus disabled status and other enrollment characteristics that affect expected cost. The second major driver is the set of valid, supported ICD-10-CM codes reported for the beneficiary during the data collection period; only certain chronic, clinically significant conditions map to HCCs, and they must be documented as active and applicable to the encounter and coded correctly. In ambulatory CDI, this is why accurate condition capture, specificity, and linkage (e.g., cause/manifestation relationships) are emphasized-because reported conditions directly affect the patient's risk profile and the expected cost benchmark. By contrast, income status is not a standard CMS-HCC input, "previous risk score" is not itself an input variable, and utilization outcomes like cost of care or readmissions are not used to compute RAF (they may be evaluated separately in quality/cost programs).
NEW QUESTION # 30
Which of the following BEST describes a Stage 3 pressure ulcer?
Answer: A
Explanation:
Stage 3 pressure ulcers are defined by full-thickness skin loss where the injury extends through the dermis and involves damage or necrosis of subcutaneous tissue. Clinically, the ulcer may present as a deep crater and can include undermining or tunneling, but the key boundary is that bone, tendon, and muscle are not exposed. That deeper involvement (exposed muscle/tendon/bone) is characteristic of Stage 4, making option C incorrect. Option D describes partial-thickness loss, which aligns with Stage 2 (epidermis/dermis involvement such as abrasion or blister). Option A reflects early skin changes that correspond more closely to Stage 1 (intact skin with non-blanchable erythema and possible localized edema/induration). In outpatient CDI chart review, accurately distinguishing Stage 3 from Stage 2 and Stage 4 is essential because staging drives severity capture, care planning (wound care interventions, debridement considerations), and quality reporting. Documentation should clearly support "full thickness," the tissue layers involved, and the absence of exposed bone/tendon/muscle.
NEW QUESTION # 31
ICD-10-CM code assignment can be supported by documentation from someone other than the patient's provider in which of the following circumstances?
Answer: D
Explanation:
Outpatient ICD-10-CM guidance allows certain code elements to be based on documentation from clinicians other than the patient's diagnosing provider when those elements are considered objective, routinely assessed, and commonly documented by nursing or ancillary staff. A key example is pressure ulcer staging, which is frequently assessed and documented by wound care nurses and other qualified clinicians as part of routine skin/wound evaluation. Because the stage drives code specificity and is an observable clinical finding, coders may use non-provider documentation to assign the stage when it is clearly documented and not contradicted by the provider record. In contrast, items such as the type of obesity generally require provider diagnosis/clinical assessment rather than ancillary documentation alone. Similarly, while status conditions (like amputations or ostomies) may be observed, the coding guidelines do not broadly permit assigning these diagnoses solely from non-provider documentation without provider confirmation, unless the chart otherwise supports it. Therefore, among the choices, pressure ulcer stage is the appropriate circumstance where non-provider documentation can support ICD-10-CM assignment.
NEW QUESTION # 32
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: C
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 # 33
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