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| Certification Vendor: | ACDIS |
|---|---|
| Exam Name: | Certified Clinical Documentation Specialist-Outpatient (CCDS-O) Exam |
| Exam Number: | CCDS-O |
| Real Exam Qty: | 140 (120 scored, 20 unscored) |
| Available Languages: | English |
| Exam Duration: | 150 minutes |
| Certificate Validity Period: | 2 years |
| Related Certifications: | Certified Clinical Documentation Specialist (CCDS) |
| Exam Price: | $280 (ACDIS members), $380 (non-members), +$100 international fee |
| Exam Format: | Computer-based, Remotely proctored or test center delivery, Multiple-choice questions |
| Passing Score: | 85 out of 120 scored questions |
| Recommended Training: | CCDS-O Exam Candidate Handbook CCDS-O Official Study Guide |
| Exam Registration: | Prometric Scheduling ACDIS Certification Application |
| 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 # 20
Which of the following actions should be taken when the documentation states: "Hemiparesis, history of CVA, and intracranial trauma?"
Answer: B
Explanation:
This documentation presents a key outpatient CDI problem: hemiparesis is present, but two potential causal conditions are referenced-history of CVA and intracranial trauma-without clear linkage. In ICD-10-CM, correct reporting of hemiparesis often depends on identifying whether it is a late effect (sequela) of a prior stroke, a residual from traumatic brain injury, or due to another neurologic condition. Coding hemiparesis automatically as a CVA sequela (option A) would be assumptive and potentially inaccurate, because the clinician has not documented the relationship. Likewise, simply coding hemiparesis alone (option D) may miss important etiologic specificity, and coding both histories without clarifying the cause (option B) still leaves the main clinical ambiguity unresolved. Outpatient CDI best practice is to issue a non-leading query requesting provider clarification of the etiology/source of the hemiparesis (e.g., due to prior CVA, due to prior intracranial trauma, both, or other/undetermined). This supports accurate diagnosis reporting, appropriate sequencing, and defensible risk/quality representation.
NEW QUESTION # 21
Documentation from which of the following facility settings contributes to the CMS-HCC risk score?
Answer: A
Explanation:
Under CMS-HCC risk adjustment (commonly applied to Medicare Advantage), qualifying diagnoses must come from acceptable encounter/claim sources and eligible provider types. Hospital-based outpatient services (including a hospital ambulatory clinic) are among the standard, acceptable settings where diagnoses documented, coded, and submitted on qualifying encounters may be used for risk adjustment-assuming they are supported, assessed/managed, and submitted per program requirements. In contrast, certain facility claim types do not typically contribute to CMS-HCC capture in the same way. Hospice care is generally treated as a carve-out/unique payment environment and is not relied upon as a routine source of risk-adjusting diagnosis capture for the member's ongoing RAF. Renal dialysis centers (ESRD facilities) likewise operate under specialized payment constructs and are not the typical outpatient setting used to drive CMS-HCC diagnosis capture for risk adjustment in standard CDI workflows. Freestanding ambulatory surgical centers also frequently fall outside the usual risk-adjustment-eligible encounter sources emphasized in outpatient CDI programs. Therefore, the hospital ambulatory clinic is the correct setting among these choices.
NEW QUESTION # 22
Which of the following is a form of a cardiac condition that may be treated with a beta-blocker?
Answer: B
Explanation:
Beta-blockers are commonly used in the management of coronary artery disease (CAD) because they lower heart rate, decrease myocardial contractility, and reduce oxygen demand-key goals in treating stable angina and in secondary prevention after myocardial infarction. In outpatient chart review, ACDIS-focused clinical documentation education emphasizes linking the medication to the condition being managed (e.g., "CAD with angina-on metoprolol for symptom control" or "history of MI-on beta-blocker for secondary prevention") to support accurate diagnosis reporting and demonstrate ongoing assessment and treatment. By contrast, third-degree (complete) heart block and sinus bradycardia are conditions where beta-blockers are typically avoided or used only with extreme caution because they can worsen conduction delay and slow the heart rate further. Cardiomyopathy can sometimes be treated with certain evidence-based beta-blockers when the clinical context is systolic heart failure, but the option most broadly and reliably associated with beta-blocker treatment in standard outpatient practice and documentation is CAD.
NEW QUESTION # 23
Which of the following is a strategy that is often used by ACOs to improve their performance in the Readmission Reduction program?
Answer: B
Explanation:
ACOs commonly focus on strengthening documentation and coding of clinically relevant chronic conditions because many quality and utilization comparisons-including readmission-related performance assessments-are influenced by patient complexity and risk adjustment. When chronic diseases and their specificity (e.g., stage, severity, manifestations) are under-documented, attributed patients can appear "healthier" on paper than they truly are, which can worsen an organization's apparent readmission performance when outcomes are compared to an expected benchmark. Provider education that reinforces documenting active conditions that are monitored, evaluated, assessed/addressed, or treated helps ensure an accurate picture of acuity and comorbidity burden. This improves the integrity of risk adjustment inputs and supports fairer benchmarking, while also strengthening medical necessity and continuity-of-care communication across settings. The other choices represent either noncompliant behavior (avoiding condition reporting), poor documentation practice (promoting unspecified codes), or operational maneuvering that may be perceived as gaming rather than a sustainable quality strategy. Therefore, educating providers to capture chronic conditions accurately is the best and most commonly used improvement approach.
NEW QUESTION # 24
A patient is seen in the obstetrical clinic, 6 weeks postpartum. She presents with resting heart rate of 58 BPM, initial blood pressure of 154/90, and respiratory rate of 20. She also complains of slight headaches, denies visual changes, and has no evidence of peripheral edema. History is significant for smoking and obesity. A blood pressure reading of 160/88 is taken at the end of the visit. The provider documents hypertension. Which of the following query opportunities is MOST appropriate?
Answer: A
Explanation:
In obstetric and postpartum coding, the most important clarification is the type/timing of hypertension because ICD-10-CM has distinct categories for chronic (pre-existing) hypertension, gestational hypertension, and hypertensive disorders that persist into or present during the postpartum period. At 6 weeks postpartum with elevated readings (including a systolic of 160) and headache, the documentation "hypertension" is not specific enough to determine whether this represents chronic hypertension that predates pregnancy, gestational hypertension that has not resolved, or another pregnancy-related hypertensive disorder requiring different obstetric coding and follow-up. ACDIS outpatient CDI guidance prioritizes queries that resolve coding-impactful ambiguity using clinically supported options without leading the provider. While postpartum preeclampsia could be a clinical consideration, the note does not provide key supporting elements (e.g., proteinuria or other definitive severe-feature criteria), so jumping directly to preeclampsia/eclampsia is less appropriate than clarifying onset and relationship to pregnancy. Linking hypertension to smoking is not a standard required linkage for diagnosis coding, and "hypertensive crisis" is not supported by the documentation provided.
NEW QUESTION # 25
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