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ACDIS CCDS-O Exam Overview:

Certification Vendor:ACDIS
Exam Name:Certified Clinical Documentation Specialist-Outpatient (CCDS-O) Exam
Exam Number:CCDS-O
Passing Score:85 out of 120 scored questions
Certificate Validity Period:2 years
Real Exam Qty:140 (120 scored, 20 unscored)
Exam Format:Multiple-choice questions, Computer-based, Remotely proctored or test center delivery
Related Certifications:Certified Clinical Documentation Specialist (CCDS)
Exam Duration:150 minutes
Exam Price:$280 (ACDIS members), $380 (non-members), +$100 international fee
Available Languages:English
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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ACDIS CCDS-O Exam Syllabus Topics:

TopicDetails
Topic 1
  • Quality, Regulatory, and Health Initiatives: Covers population health, MSSP, ACO models, MACRA
  • MIPS, compliant query development, RADV audits, OIG compliance, problem list maintenance, and HIPAA requirements in outpatient CDI.
Topic 2
  • Coding and Reporting, the Outpatient Prospective Payment System (OPPS), and provider coding
Topic 3
  • Risk Adjustment Models and Impact of Documentation and Coding: Covers CMS-HCC model fundamentals, RAF scoring, Medicare Advantage payments, hierarchies, disease interactions, and compliant HCC reporting requirements.
Topic 4
  • 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 5
  • Healthcare regulations, reimbursement, and documentation requirements related to the Official Guidelines for

ACDIS Certified Clinical Documentation Specialist-Outpatient Sample Questions (Q79-Q84):

NEW QUESTION # 79
A patient is scheduled to see his PCP in 3 days. A CDI specialist notes that during the patient's last visit earlier this year, the problem list shows both DM 2 associated erectile dysfunction and DM 2 without complications. The last clinic note states that DM 2 with autonomic neuropathy was addressed. The CDI specialist should do which of the following FIRST?

Answer: B

Explanation:
The record contains conflicting documentation: the problem list includes both "type 2 diabetes without complications" and diabetes with complications (erectile dysfunction association), while the most recent clinic note indicates the provider addressed "DM2 with autonomic neuropathy," which is clearly a diabetic complication. In outpatient CDI, the first priority is to resolve internal inconsistency so coding accurately reflects the patient's current clinical status and what was evaluated/managed at the encounter. A query should therefore focus on whether the patient's diabetes is with complications (and which complications are active/being addressed) versus truly without complications, because "without complications" is generally not appropriate when neuropathy/other manifestations are present and being managed. CDI staff also should not unilaterally remove items from the provider-maintained problem list, and asking the patient is not a reliable documentation/coding source for establishing diagnoses. Once the provider clarifies diabetes complication status, a follow-up clarification can address specific linkages (e.g., erectile dysfunction due to diabetes) if needed for correct code assignment


NEW QUESTION # 80
A patient presents to the PCP's office with LLE edema and pain for 3 days. The problem list indicates morbid obesity and a history of DVT. Vital signs are T 37.9, P 76, R 12, BP 142/88, BMI 46. Documentation states: "Patient presents with LLE edema, increased pain, and hx of DVT. Sedentary lifestyle and contraindications to anticoagulation therapy. LLE warm to touch, 3+ edema from ankle to knee. Pedal pulses 2+ on L and 3+ on R." Doppler exam indicates DVT. The PCP should be queried for which of the following diagnoses?

Answer: D

Explanation:
The documented indicators strongly support two clarification needs that affect accurate outpatient reporting. First, morbid obesity is supported by an objective BMI of 46, and outpatient CDI practice emphasizes ensuring obesity class is clearly documented as a diagnosis (not only implied by BMI) and that it is clinically relevant to care planning and risk (e.g., contributes to thrombotic risk, impacts treatment options). Second, the Doppler "indicates DVT," but the record also notes a history of DVT, creating ambiguity about status-is this an acute new/recurrent DVT, a chronic/residual thrombosis, or a prior condition now re-identified? Clarifying acuity/status is essential because it changes code selection and clinical severity representation and supports medical necessity for management decisions, especially given "contraindications to anticoagulation." Hypertensive urgency is not supported (BP 142/88 without crisis features), and "hypercoagulability" is not established by the provided indicators. Therefore, querying for morbid obesity and DVT status is most appropriate.


NEW QUESTION # 81
When a CDI specialist identifies a discrepancy in documentation, the next step is to:

Answer: B

Explanation:
CDI staff do not alter the legal health record and should not "code it as is" when documentation is unclear, conflicting, or incomplete in a way that impacts accurate reporting. The compliant next step is to issue a provider query for clarification, ensuring the final record accurately reflects the provider's clinical judgment. ACDIS-guided outpatient CDI emphasizes that queries are a quality and compliance tool: they reconcile discrepancies (e.g., conflicting diagnoses across notes, missing linkage between symptoms and conditions, unclear acuity such as "CHF" without type/status, or ambiguous infection documentation). The query should be supported by clinical indicators from the chart and should ask the provider to document the clarified diagnosis/status in the record (progress note, addendum, or appropriate attestation). Escalation to compliance is reserved for patterns of nonresponse, suspected integrity concerns, or systemic issues, not routine discrepancies. The objective is to achieve a complete, consistent clinical story that supports coding, risk adjustment, quality reporting, and medical necessity-through provider clarification, not CDI edits.


NEW QUESTION # 82
Along with history and examination, which of the following is considered a key component in reporting evaluation and management services?

Answer: D

Explanation:
For reporting Evaluation and Management (E/M) services, the longstanding "key components" framework recognizes history, examination, and medical decision making (MDM) as the core elements used to determine the appropriate E/M level when the service is not reported based on time. In outpatient CDI education aligned with ACDIS concepts, MDM is emphasized because it reflects the clinician's cognitive work and risk-based thinking: the complexity of problems addressed, the amount/complexity of data reviewed and analyzed (labs, imaging, external notes, independent interpretation), and the risk of complications and/or morbidity from additional testing or treatment. "Review of systems" is a sub-element of the history component, not a separate key component. "Nature of presenting problem" and "coordination of care" can be clinically relevant and may support medical necessity or time-based billing (when documented appropriately), but they are not one of the three key components that define E/M reporting structure. Therefore, the best answer is Medical decision making.


NEW QUESTION # 83
Which of the following is the major difference between MIPS and APMs?

Answer: B

Explanation:
MIPS (Merit-based Incentive Payment System) is the default Medicare Quality Payment Program pathway for most eligible clinicians who are not sufficiently participating in an Advanced APM. In practice, if a clinician is MIPS-eligible and does not meet reporting requirements (or performs poorly), Medicare applies a negative payment adjustment-so "non-participation" effectively carries financial risk. APMs (Alternative Payment Models), especially Advanced APMs, are not automatically required for all clinicians; they are model-based arrangements (often tied to specific payers, contracts, patient populations, and risk/quality terms) that clinicians typically enter through organizational participation decisions. A key operational difference emphasized in outpatient CDI education is that MIPS performance hinges on accurate, complete documentation supporting quality measures and resource use across a broad clinician population, whereas APM participation depends on being in a qualifying model and meeting its participation/threshold rules. Therefore, MIPS functions as the required/default track with potential penalties, while APM participation is elective and model-dependent.


NEW QUESTION # 84
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