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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) |
| Exam Format: | Computer-based exam, Multiple-choice |
| Available Languages: | English |
| Passing Score: | 85 out of 120 scored questions |
| 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 # 27
An African American male enrolled in Medicaid has not been taking his blood pressure medication. Which of the following factors impacts this beneficiary's risk score?
Answer: B
Explanation:
Medicaid risk adjustment models generally calculate risk using two major categories of inputs: demographics and diagnosis data. Demographic factors commonly include gender and indicators tied to Medicaid status/eligibility (for example, eligibility category, dual status, disability-related eligibility, or other program qualifiers depending on the state/model). These demographic elements adjust expected cost and are foundational to the risk score even before considering diagnoses. By contrast, race is not a standard input for calculating Medicaid risk scores in typical risk adjustment methodologies, so options that include race are not supported. Likewise, "patient noncompliance" is primarily a clinical and quality-of-care issue and may affect treatment outcomes, but it is not itself a standard risk-score driver unless it is documented as a reportable, supported diagnosis that the specific model recognizes (and most models don't directly risk-adjust for nonadherence codes). Therefore, among the options given, Medicaid status and gender are the most clearly valid factors that impact the beneficiary's risk score.
NEW QUESTION # 28
PCP notes describe the presence of atrial fibrillation for 10 days. Atenolol, sotalol and rivaroxaban are ordered. Possible ablation is discussed. Identify the type of atrial fibrillation described in this clinical scenario.
Answer: B
Explanation:
Atrial fibrillation (AF) type is determined largely by episode duration and whether the rhythm self-terminates. In outpatient CDI education, paroxysmal AF is intermittent and typically terminates spontaneously, commonly within 7 days (often within 48 hours). Persistent AF is sustained and lasts more than 7 days, or requires active intervention (e.g., cardioversion) to restore sinus rhythm. This scenario documents AF "for 10 days," which exceeds the 7-day threshold and therefore best fits persistent AF. The management also aligns with a sustained arrhythmia strategy: rate control (atenolol), rhythm control/antiarrhythmic therapy (sotalol), stroke prevention anticoagulation (rivaroxaban), and discussion of catheter ablation, which is often considered for symptomatic or recurrent/persistent AF. "Chronic" is a nonspecific descriptor and not the preferred current classification term, and permanent AF implies a decision has been made not to pursue rhythm control (accepting AF long-term), which is not supported here because rhythm-control options are being considered.
NEW QUESTION # 29
Upon retrospective review of a patient visit 2 weeks prior, a CDI specialist notes physician documentation stating the following: "Sick Sinus Syndrome in 2016 s/p pacemaker placement. Latest EKG shows normal paced rhythm." There are no codes noted for Sick Sinus Syndrome or the pacemaker. Which of the following is the BEST course of action for the CDI specialist?
Answer: D
Explanation:
In outpatient CDI, diagnoses reported for an encounter must be supported as current and clinically relevant to that visit (evaluated, monitored, assessed, treated, or otherwise affecting care). The note documents a history of sick sinus syndrome with pacemaker placement in 2016 and indicates the current rhythm is paced. The most clearly reportable, present condition is the presence of a cardiac pacemaker, which is a status that can affect clinical decision-making (e.g., interpretation of rhythm findings, medication choices, procedures, and future cardiac evaluation) and is appropriate to code when documented. However, the documentation does not show that sick sinus syndrome itself was actively assessed or managed during this visit; it is referenced as a past condition leading to the device. Because outpatient coding does not assume an active diagnosis solely from historical mention, the best action is to capture the pacemaker status code only. Retrospective amendment requests or rebilling steps are not the first-line CDI action when the documentation does not support active management of the underlying arrhythmia.
NEW QUESTION # 30
A patient returns to a PCP for follow-up care related to a UTI. The provider documents "stage 3 CKD" as determined by a single eGFR of 52 mL/min. Which of the following actions should the CDI specialist take?
Answer: A
Explanation:
The CDI specialist should review CKD staging criteria with the provider because assigning CKD based on a single eGFR value can be clinically unreliable and may lead to inaccurate documentation and coding. Outpatient CDI guidance emphasizes that documentation must reflect a condition that is clinically valid, supported by the record, and accurately described, especially for chronic diseases. CKD is generally established by evidence of decreased kidney function or kidney damage that is persistent, not a one-time lab that could be affected by hydration status, acute illness, medications, or transient physiologic changes. While an eGFR of 52 falls within the numeric range commonly associated with stage 3a, the key CDI issue is the foundation for diagnosing chronic disease, not simply whether the number is "reportable." Option A inappropriately directs CDI to add diagnoses to claims; CDI supports providers and coding, but does not independently "add" conditions. Option C is incorrect because chronic conditions may be coded when addressed/impact care, not only when actively treated. Option D is unsupported because eGFR 52 does not suggest stage 4.
NEW QUESTION # 31
Which diagnosis and treatment plan may generate a query?
Answer: C
Explanation:
Outpatient CDI queries are most commonly triggered when there is a disconnect between the documented diagnosis and the documented treatment plan, suggesting that the clinician may be managing an additional condition that is not clearly stated, or that the diagnosis is inaccurately documented. Options A and B reflect typical, clinically aligned management: luteinizing hormone-releasing hormone therapy is a standard treatment pathway for prostate carcinoma, and amiodarone is a recognized antiarrhythmic used in atrial fibrillation management in appropriate circumstances. Option C can also be clinically consistent because parenteral nutrition is often used when malnutrition is present and the patient cannot meet nutritional needs enterally. Option D is the outlier: "immunotherapy" is not a standard treatment for severe major depressive disorder and more commonly aligns with oncology or certain immune-mediated diseases. This mismatch would appropriately prompt a query to clarify the actual condition being treated (e.g., an active malignancy) or to confirm whether "immunotherapy" refers to something else (such as allergy immunotherapy) and whether depression is the correct, visit-relevant diagnosis being addressed.
NEW QUESTION # 32
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