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ACDIS CCDS-O Exam Syllabus Topics:

Topic	Details
Topic 1	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 2	Healthcare regulations, reimbursement, and documentation requirements related to the Official Guidelines for
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	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.

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ACDIS Certified Clinical Documentation Specialist-Outpatient Sample Questions (Q22-Q27):

NEW QUESTION # 22
CMS-HCCs are used to

A. determine capitation payments to insurers that administer Medicare Advantage health plans.
B. adjust capitation payments to physicians, excluding advanced practice providers.
C. distribute reimbursement to providers based on quality of care.
D. reimburse physicians based on the principal diagnosis.

Answer: A

Explanation:
The CMS-HCC model is a risk adjustment methodology used primarily to set capitated payments for Medicare Advantage (MA) organizations based on the expected cost of caring for their enrolled beneficiaries. Under this approach, CMS calculates a Risk Adjustment Factor (RAF) for each member using demographic variables (such as age/sex and certain entitlement factors) plus disease burden captured from ICD-10-CM diagnoses that map to Hierarchical Condition Categories (HCCs). The resulting RAF increases or decreases the plan's payment to better match predicted healthcare needs-higher RAF for sicker, more complex patients and lower RAF for healthier patients. ACDIS outpatient CDI education emphasizes that the purpose is not physician reimbursement based on a "principal diagnosis" (an inpatient concept) and not payment distribution tied directly to quality performance (that aligns more with MIPS/VBP frameworks). It also does not adjust capitation payments specifically "to physicians," nor does it exclude advanced practice providers in the way described. The correct use is to determine MA plan capitation payments through risk-adjusted member-level projections.

NEW QUESTION # 23
Which of the following illustrates an example of a compliant, prospective query?

A. "Dr.: Your patient was here for her Annual Wellness Visit. A review of her medication list shows a new order for Lasix 20mg QD. A review of your progress note from that visit notes 2+ pitting edema bilaterally and that the patient complains of shortness of breath at night requiring her to sleep on 2 pillows. Please add CHF to the problem list if this is the diagnosis you are treating with the Lasix."
B. "Dr.: Your patient has a past medical history of CHF noted in her problem list. A review of her medication list shows Lasix 20 mg QD. Please review this diagnosis for pertinence and relevance during her upcoming visit and specify the type and acuity of the CHF if the diagnosis is still being addressed."
C. "Dr.: Your patient was ordered an echocardiogram at her last visit. Can you please document that the CHF was addressed as the basis for the study?"
D. "Dr.: Your patient has chronic diastolic heart failure documented in her problem list. Can you please add this diagnosis to your progress note from her office visit?"

Answer: B

Explanation:
A compliant prospective query is initiated before the next encounter so the provider can clarify documentation during the upcoming visit, using clinically relevant indicators without directing a specific diagnosis. Option A does this appropriately: it references an existing CHF history and a supportive medication (Lasix), then asks the provider to confirm whether CHF is pertinent at the next visit and, if so, to specify type and acuity. This supports accurate outpatient reporting because heart failure coding requires specificity (systolic/diastolic/combined; acute/chronic/acute on chronic) and should reflect what is actually evaluated/managed at the encounter. Option B is retrospective and attempts to justify a prior test. Option C is leading because it asks the provider to "add" a diagnosis to a past note rather than clarify current clinical status. Option D is also retrospective and uses "please add CHF," which is leading and can be perceived as prompting. Therefore, A best demonstrates a compliant prospective query.

NEW QUESTION # 24
Which of the following is a provider benefit of a prospective query?

A. Defines the purpose of the encounter
B. Instructs the provider to the best diagnosis to use
C. Guarantees risk adjusted diagnosis capture
D. Addresses the query topic during the actual patient encounter

Answer: D

Explanation:
A prospective query is initiated early enough (before or during the visit workflow) so the provider can evaluate, assess, and document the condition in real time while the patient is present. This is a major provider benefit because it supports better clinical accuracy and completeness: the clinician can ask targeted questions, perform relevant exam elements, review results, and determine whether the condition is present, active, being monitored, or ruled out-then document the final clinical impression and plan. From an ACDIS outpatient CDI perspective, prospective querying improves efficiency and reduces retrospective "chart-chasing," late addenda, and documentation gaps that occur when clarification is requested after the encounter is closed. Importantly, prospective queries must remain non-leading and cannot direct the provider to a particular diagnosis (eliminating option A). They also cannot "guarantee" risk-adjusted capture because the diagnosis must be clinically supported and addressed (eliminating option B). Defining the purpose of the encounter is driven by the clinical reason for visit, not by CDI (eliminating option D).

NEW QUESTION # 25
A CDI specialist identifies an opportunity to clarify a patient's BMI. The CDI specialist leaves a query within the medical record for the ancillary support team to address during the patient's visit. Which of the following BEST describes this type of query?

A. Prebill
B. Concurrent
C. Prospective
D. Retrospective

Answer: C

Explanation:
This scenario describes a query placed before the patient is seen, with the intent that the issue be addressed during the upcoming visit. In outpatient CDI practice, that is the defining feature of a prospective query: it is initiated ahead of the encounter so the provider and/or clinic team can capture needed specificity in real time (here, clarifying BMI-related documentation to support an obesity diagnosis when clinically appropriate). By contrast, a concurrent query is typically issued while the encounter is actively occurring or immediately as documentation is being created and reviewed in near-real time. A retrospective query occurs after the visit is completed, usually during post-encounter review, when opportunities are identified after documentation is finalized. "Prebill" refers to a workflow timing concept tied to billing hold/review before claim submission, not the clinical timing of when the patient will be seen. Because the query is placed in advance specifically to be addressed during the scheduled visit, prospective is the best classification.

NEW QUESTION # 26
A patient receives treatment for diabetes during a primary care visit. He has a glucose level of 240 and A1C of 7.9. The patient is prescribed Gabapentin 100mg TID. Which of the following should the CDI specialist query for?

A. Diabetes with chronic kidney disease
B. Diabetes with ketoacidosis
C. Diabetes with peripheral neuropathy
D. Diabetes with macular degeneration

Answer: C

Explanation:
In outpatient CDI chart review, a key skill is recognizing when medications and treatment plans suggest a specific diabetic complication that is not explicitly documented. Gabapentin is commonly prescribed for neuropathic pain, and in a diabetic patient it is frequently used to treat diabetic peripheral neuropathy symptoms (burning, tingling, numbness, shooting pain). ACDIS outpatient CDI guidance supports querying when there are strong clinical indicators that a more specific, clinically relevant diagnosis may be present and is being treated at the encounter, because diabetes codes require complication specificity when supported (e.g., "diabetes with neuropathy" rather than unspecified diabetes). The elevated glucose and A1C confirm ongoing diabetes management but do not, by themselves, indicate CKD, macular degeneration, or ketoacidosis. Ketoacidosis would require documentation of acute metabolic decompensation and supporting clinical/lab findings, which are not provided here. Therefore, the most appropriate clarification is whether the patient has diabetic peripheral neuropathy (and whether it is painful neuropathy) being managed with gabapentin, so the provider can document the condition clearly and accurately.

NEW QUESTION # 27
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