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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 |
| Related Certifications: | Certified Clinical Documentation Specialist (CCDS) |
| Available Languages: | English |
| Exam Format: | Computer-based exam, Multiple-choice |
| Real Exam Qty: | 140 questions (120 scored) |
| Passing Score: | 85 out of 120 scored questions |
| 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 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 # 120
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 # 121
An elderly patient with a PMH of CHF, DM type 1, arthritis, and HTN is seen in the clinic for a follow-up appointment after a recent hospitalization. After an evaluation of the patient's current health status, the provider documents the following: "HFrEF: lungs clear, no edema, continue meds. DM: no changes to insulin pump. Arthritis: asymptomatic joint destruction. HTN: BP stable. Continue meds." Which of the following is the clarification opportunity in the above scenario?
Answer: A
Explanation:
This encounter documents both hypertension and heart failure management, creating a key outpatient documentation/coding clarification opportunity: whether the heart failure is related to hypertension (hypertensive heart disease with heart failure). Outpatient CDI principles emphasize capturing the true clinical relationships that affect code assignment, risk adjustment, and longitudinal disease management. When HTN and HF coexist, coding may require combination coding and correct sequencing, plus an additional heart failure code to describe the specific HF type. Provider documentation that explicitly links (or explicitly rules out) a causal relationship supports compliant selection of the most accurate diagnosis codes and reduces ambiguity during chart review. The other options are weaker: the provider already documents HFrEF (type), and while added severity detail can help, the scenario's primary clarification "opportunity" is the HTN-HF relationship. DM type 1 inherently involves insulin, so "insulin status" is not the key outpatient clarification point here, and there is no typical direct linkage between DM and arthritis supported by the note.
NEW QUESTION # 122
During a PCP visit, a provider notes a patient's history of pathological fracture of the thoracic spine related to osteoporosis. Documentation states: "Decreased muscle mass and significant weight loss in the last six months." Which of the following should the CDI specialist query for?
Answer: B
Explanation:
The documentation "decreased muscle mass and significant weight loss in the last six months" raises a strong clinical indicator for a nutrition-related condition (e.g., malnutrition, cachexia, or other clinically significant weight loss) that should be clarified by the provider. In outpatient CDI practice, ACDIS-based guidance emphasizes querying when there are objective or clearly stated indicators suggesting an additional diagnosis that is clinically relevant, affects management, or reflects patient complexity. Malnutrition is particularly important because it can explain functional decline, frailty, and increased risk of falls/fractures, and it often changes the care plan (dietary counseling, nutrition referral, supplementation, labs, monitoring). While "degree of muscle atrophy" and "acuity of the fracture" could matter in other contexts, the note explicitly highlights a systemic decline over six months rather than an acute fracture issue. "Type of osteoporosis" is relevant for specificity, but the new, clinically significant clue here is unintended weight loss with muscle wasting-making malnutrition the most appropriate clarification opportunity.
NEW QUESTION # 123
In which of the following ways does payment determination (risk score calculation) differ between HHS-HCCs and CMS-HCCs?
Answer: D
Explanation:
A key ambulatory CDI distinction between the two major risk models is timing. The HHS-HCC model (used for ACA Marketplace risk adjustment) is commonly described as a concurrent model: it uses the enrollee's demographics and diagnoses from the same benefit year to reflect morbidity and support that year's risk transfer/payment balancing. In contrast, the CMS-HCC model (commonly applied in Medicare Advantage) is prospective: conditions documented and coded in the prior data collection year are used to predict expected cost for the following payment year. From an outpatient CDI perspective, this timing difference affects operational priorities. For CMS-HCC, accurate annual capture and recapture of active chronic conditions is essential because last year's documented conditions drive next year's risk score and revenue. For HHS-HCC, complete documentation and coding during the current year impacts the current year's risk measurement. Options referencing CPT codes are not correct for the core HCC risk score calculation, which is driven by demographics and ICD diagnosis reporting mapped to HCC categories.
NEW QUESTION # 124
A CDI specialist receives a call from a disgruntled provider regarding recent documentation queries. The provider claims to only have 15 minutes to see patients and does not have time for interruptions like this if it does not increase reimbursement. Which of the following is the BEST course of action to effectively facilitate communication?
Answer: D
Explanation:
Effective outpatient CDI depends on provider engagement, efficient workflows, and respectful communication. When a provider is frustrated about time pressures, the most productive approach is to partner with them to reduce friction while preserving compliant documentation improvement. ACDIS outpatient CDI concepts emphasize collaboration and provider education-meeting the provider where they are, understanding their workflow constraints, and jointly designing a query process that is minimally disruptive (e.g., batching queries, aligning with clinic schedules, using prospective queries, leveraging templates, or routing through agreed channels). Option C directly addresses the root issue (workflow burden) and builds trust by seeking the provider's input and scheduling the discussion at their convenience. Option A is confrontational and frames CDI as a compliance demand rather than a clinical accuracy initiative. Option B is inappropriate because CDI cannot stop querying when clarification is needed for accurate documentation, coding, quality reporting, and risk adjustment. Option D escalates prematurely and damages relationships; escalation is typically reserved for persistent, unresolved non-responsiveness after collaborative efforts and leadership-supported education.
NEW QUESTION # 125
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