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ACDIS CCDS-O Exam Overview:

Certification Vendor:	ACDIS
Exam Name:	Certified Clinical Documentation Specialist-Outpatient
Exam Number:	CCDS-O
Related Certifications:	CCDS
Exam Format:	Application & Analysis, Multiple Choice, Scenario-Based Items
Available Languages:	English
Sample Questions:	ACDIS CCDS-O Sample Questions
Exam Way:	Proctored at testing centers
Pre Condition:	Candidates must have a background in healthcare, coding, or clinical documentation.
Official Syllabus URL:	https://acdis.org/certifications/certified-clinical-documentation-specialist-outpatient

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ACDIS CCDS-O Exam Syllabus Topics:

Topic	Details
Topic 1	Diseases and Disease Processes and Application to the Clinical Chart Review: Covers clinical indicators across all ICD-10-CM chapters, applied to chart reviews, with recognition of medications, diagnostic tests, and abbreviations as documentation clarification triggers.
Topic 2	CDI Program Concepts: Department Metrics and Provider Education: Covers provider education development, CDI performance metrics including query rates, RAF progression, HCC capture, ACO MSSP impact, and physician documentation's effect on quality reporting.
Topic 3	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 4	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 5	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 6	Coding and Reporting, the Outpatient Prospective Payment System (OPPS), and provider coding

ACDIS Certified Clinical Documentation Specialist-Outpatient Sample Questions (Q86-Q91):

NEW QUESTION # 86
Which of the following is the MOST compliant provider query?

A. "Noted that the patient has skin that is 'warm and dry with no rashes or lesions'; however, nursing documentation describes a 'stage 3 sacral pressure ulcer' requiring wet-to-dry dressing changes. Please add the pressure ulcer to your ED assessment note if appropriate."
B. "The patient has a past medical history of CAD, HF, and COPD. Please document these conditions during the encounter today if they are still being treated."
C. "Noted that this patient is being referred for a colonoscopy. She has no documented GI symptoms and has a family history of colon cancer. When this patient is seen, please clarify whether this is a screening colonoscopy or diagnostic colonoscopy."
D. "According to a visit last year, this patient has a history of alcohol use; quit two years ago; previously drank 6-9 beers daily, 10-12 beers on weekend. Patient now attends AA meetings. Is the patient's alcohol use now in remission?"

Answer: C

Explanation:
The most compliant query is the one that is clinically supported, non-leading, and focused on clarifying documentation for correct reporting and medical necessity-without directing the provider to "add" diagnoses or document conditions for payment purposes. Option A presents relevant clinical context (no GI symptoms; family history) and asks the provider to clarify whether the planned colonoscopy is screening or diagnostic, which is a legitimate documentation clarification affecting correct code selection and coverage rules. It does not imply a desired answer and does not instruct the provider to document additional diagnoses. Option B is problematic because it instructs the provider to "document these conditions" if treated, which can be perceived as prompting and is not tied to encounter-specific indicators. Option C is based primarily on historical information and asks a yes/no about remission, which can be leading and may not reflect current-visit evaluation. Option D effectively asks the provider to add a diagnosis based on nursing documentation, which risks leading language and requires provider confirmation and assessment. Therefore, A is most compliant.

NEW QUESTION # 87
When compliantly querying providers, CDI specialists or HIM/coding professionals may

A. omit clinical indicators in a query as this may be leading to the provider.
B. identify which diagnoses are HCCs.
C. offer a new diagnosis, that is supported by the clinical evidence, as an option in a multiple-choice query.
D. offer diagnoses choices supported by documentation solely from previous encounters.

Answer: C

Explanation:
Compliant querying principles taught in outpatient CDI allow the CDI/coding professional to present a multiple-choice query that includes reasonable diagnostic options supported by the current encounter's clinical indicators. Including a "new" diagnosis as an option is acceptable when it is clinically supported by documented findings (signs/symptoms, test results, treatments, clinical course) and the query is written in a non-leading manner-typically with balanced options and an "other" and/or "unable to determine" choice. This approach helps the provider clarify the most accurate condition being evaluated or treated without steering toward a particular response. Option A is not compliant because relying solely on prior encounter documentation (without current relevance) risks coding historical conditions that are not addressed today. Option B is generally discouraged because calling out HCC status can be perceived as prompting for payment impact rather than clinical accuracy. Option D is incorrect because including relevant clinical indicators is essential; omitting them weakens the clinical basis and does not make a query less leading-rather, it makes it less defensible.

NEW QUESTION # 88
Which of the following statements is true regarding RADV reviews?

A. Acceptable physician authentication includes hand-written or electronic signatures.
B. Conditions reported must be documented in the final visit diagnoses or facesheet of the medical record.
C. Diagnoses assigned by technicians are considered during RADV reviews.
D. Diagnoses assigned by a diagnostic radiologist are considered during RADV reviews.

Answer: A

Explanation:
RADV (Risk Adjustment Data Validation) is an audit process used to validate that risk-adjusting diagnoses submitted for payment are supported by compliant medical record documentation. A foundational requirement is that the record is properly authenticated by an acceptable provider-meaning the documentation must be attributable to the treating clinician through a valid signature. In compliant documentation standards emphasized in outpatient CDI education, acceptable authentication may be a traditional hand-written signature or an electronic signature/attestation that meets organizational and regulatory policy. Option B is not correct because diagnoses do not have to appear only on a facesheet or "final diagnosis" list; they may be supported within the body of the note (assessment/plan, problem-based charting, or other authenticated sections) as long as they are clearly documented and clinically supported. Options A and D are not reliably true statements in a general RADV context because RADV focuses on diagnoses supported by appropriate provider documentation and acceptable encounter record criteria; "technician-assigned" diagnoses are not acceptable, and radiology documentation alone may not meet all validation expectations depending on the program's rules and encounter context.

NEW QUESTION # 89
A patient presents with pulmonary rales, pulmonary edema found on chest x-ray, and bilateral ankle edema. Which of the following conditions will the provider MOST likely evaluate further?

A. Pleural effusion
B. Heart failure
C. Pneumonia
D. Pulmonary hypertension

Answer: B

Explanation:
Pulmonary rales (crackles), radiographic pulmonary edema, and peripheral (ankle) edema together strongly suggest a systemic volume overload state, most classically due to heart failure. In ambulatory CDI chart review, these findings function as clinical indicators that drive the provider's diagnostic reasoning and typically prompt further evaluation of heart failure type and status (e.g., acute vs chronic, systolic vs diastolic, preserved vs reduced EF), along with assessment of severity and potential decompensation. Providers commonly correlate these indicators with additional data such as weight gain trends, BNP, echocardiogram findings, medication adherence (diuretics), and signs of congestion to determine whether the patient is experiencing a heart failure exacerbation requiring treatment adjustments. While pleural effusion may coexist and pneumonia can cause rales, the presence of pulmonary edema on chest x-ray plus bilateral ankle edema points more directly to a cardiac/volume etiology than an isolated infectious process. Pulmonary hypertension may contribute to dyspnea and edema but does not most directly explain pulmonary edema on imaging in the same way. Therefore, heart failure is the most likely condition to be evaluated further.

NEW QUESTION # 90
Along with history and examination, which of the following is considered a key component in reporting evaluation and management services?

A. Coordination of care
B. Review of systems
C. Nature of presenting problem
D. Medical decision making

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 # 91
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