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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 |
| Passing Score: | 85 out of 120 scored questions |
| Available Languages: | English |
| Related Certifications: | Certified Clinical Documentation Specialist (CCDS) |
| Exam Format: | Multiple-choice, Computer-based exam |
| Real Exam Qty: | 140 questions (120 scored) |
| 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 # 52
Which of the following is a key component that is used to calculate Relative Value Units (RVUs)?
Answer: C
Explanation:
RVUs are the foundation of Medicare's physician fee schedule methodology and are built from three core components: physician work (wRVU), practice expense (peRVU), and malpractice (mpRVU). The malpractice expense RVU reflects the relative professional liability insurance cost associated with providing a service and is a defined element of the RVU calculation used to determine payment rates. In outpatient documentation and CDI education, it's important to distinguish what drives code selection versus what is a payment calculation ingredient. Time with the patient and medical decision making influence E/M code selection under current E/M rules, but they are not standalone components of the RVU formula itself-they contribute indirectly by determining which CPT code is billed, and each CPT code has preassigned RVUs. Physician specialty type also is not a direct RVU component, even though specialty patterns can affect typical service mix and overall wRVU productivity. Therefore, among the options, malpractice expense is the explicit RVU component used in the calculation.
NEW QUESTION # 53
A CDI specialist is following up on a query while the provider is seeing patients in the clinic. The BEST action that will support a quick and compliant response to the query is to
Answer: C
Explanation:
Outpatient CDI follow-up must balance responsiveness with confidentiality and professional standards. The most compliant approach is to communicate query-related information in a setting that protects protected health information and minimizes the risk of incidental disclosure. Discussing the query in a private room with the door closed supports timely clarification while maintaining privacy, avoiding conversations that could be overheard by patients, visitors, or staff who are not involved in the patient's care. Catching the provider in the hallway is faster but increases privacy risk because clinical details can be overheard, and it may also distract the provider in a high-traffic environment. Leaving a sticky note on the next patient's chart is inappropriate because it can be seen by others, may be misplaced, and can create compliance and medico-legal concerns (including mixing patients or leaving PHI unsecured). Waiting for the next scheduled meeting may be compliant but does not support a quick response, potentially delaying coding completion and data integrity. Therefore, a private discussion is both the quickest and most compliant option.
NEW QUESTION # 54
The primary purpose of the RADV program is to
Answer: A
Explanation:
RADV (Risk Adjustment Data Validation) is a CMS audit program used in Medicare Advantage to confirm that diagnoses submitted for risk adjustment are supported by medical record documentation and meet reporting requirements. Its central aim is payment integrity-ensuring that risk-adjusted capitation payments to Medicare Advantage organizations are accurate based on valid, documented conditions. In outpatient CDI practice, RADV risk underscores why documentation must clearly support each reported diagnosis (e.g., condition evaluated/assessed/treated, clinically relevant, and properly documented by an eligible provider), because unsupported diagnoses can lead to payment recoupment and compliance exposure. RADV is not designed to assess medical necessity of the services provided (that is typically addressed through utilization review and other payer audits), nor is it focused on identifying overpayments to individual physicians (it targets plan-level risk adjustment payments). It also is separate from E/M leveling accuracy, which is governed by CPT/E/M guidelines and distinct audit processes. Therefore, the best definition of RADV's primary purpose is ensuring the integrity and accuracy of risk-adjusted payments.
NEW QUESTION # 55
Which of the following conclusions can be drawn from the impact of a CDI program on Clinic A using the table below?
Answer: C
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 # 56
When reviewing physician metrics, a CDI specialist notes upward trends in the use of unspecified diagnoses. Which of the following diagnoses provides the BEST opportunity to positively influence the providers' RAF score in the CMS-HCC model?
Answer: C
Explanation:
In CMS-HCC risk adjustment, RAF impact comes from reporting qualifying chronic diseases (HCCs), not from nonspecific symptom-only documentation. "Angina pectoris, unspecified" is frequently a symptom-level statement and, by itself, often does not carry the same risk-adjustment weight as documenting and coding the underlying ischemic heart disease responsible for the angina (for example, coronary artery disease/atherosclerotic heart disease with angina). Ambulatory CDI practice emphasizes that when providers document only "angina," coders may be limited to a symptom code, which can under-represent the patient's true disease burden in the HCC model. This makes angina an excellent target for provider education: clarify whether the angina is due to CAD, whether CAD is present and being managed, and whether there are related manifestations (e.g., unstable angina, prior MI history, status post CABG/stent) that support more complete, clinically accurate reporting. By improving documentation linkage from symptom (angina) to the definitive chronic condition (CAD with angina), the provider can more reliably capture an HCC-relevant diagnosis and positively influence RAF accuracy.
NEW QUESTION # 57
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