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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	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 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.

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ACDIS Certified Clinical Documentation Specialist-Outpatient Sample Questions (Q10-Q15):

NEW QUESTION # 10
A record review conducted prior to a primary care appointment indicates a patient has been followed for history of colon cancer. The patient is 18 months s/p bowel resection and is under treatment for LLE DVT, which required monitoring of INR - on Coumadin. The problem list also includes obesity, obstructive sleep apnea (OSA), COPD, and hypertension. Which of the following is the query opportunity?

A. Status of ostomy
B. Status of the COPD
C. Status of the sleep apnea
D. Status of colon cancer

Answer: D

Explanation:
In outpatient CDI, a prime query opportunity is any diagnosis with unclear "status" that materially affects coding, risk adjustment, surveillance, and care planning. "History of colon cancer" paired with "18 months s/p bowel resection" creates ambiguity: the provider must clarify whether the malignancy is still active (current disease, recurrence, metastasis, ongoing treatment) versus no longer present (history of malignancy, in remission, disease-free status, post-treatment surveillance only). This distinction changes code selection substantially and prevents inappropriate reporting of an active cancer when the encounter is actually follow-up after curative treatment. By contrast, ostomy status is not documented as present, and OSA/COPD "status" may be clinically useful but is not inherently ambiguous from the prompt in the same way (they are listed as chronic problems without a conflicting timeline event). ACDIS outpatient CDI practice prioritizes clarifying cancer status because it impacts longitudinal documentation integrity, accurate problem list management, and compliant diagnosis reporting at each visit.

NEW QUESTION # 11
CMS-HCC risk adjustment methodology seeks to measure

A. physician cost of care provision.
B. group beneficiary costs.
C. an individual's anticipated cost of care.
D. a beneficiary's risk of mortality.

Answer: C

Explanation:
The CMS-HCC risk adjustment methodology is designed to estimate an individual beneficiary's expected healthcare resource use and cost relative to an average Medicare beneficiary. It does this by converting demographic factors (such as age/sex and certain eligibility variables) plus documented, coded chronic conditions into a Risk Adjustment Factor (RAF). That RAF is then used to forecast the likely cost of caring for that specific patient in the payment year and to adjust benchmarks/payments so plans and providers managing sicker patients are compared more fairly to those managing healthier patients. This is why outpatient CDI emphasizes accurate, specific documentation and annual recapture of active conditions that are monitored, evaluated, assessed/addressed, or treated-because those coded conditions drive the predicted cost profile. CMS-HCC is not a mortality prediction tool (eliminating B), nor is it intended to measure "group costs" as the primary target (C), even though aggregated risk scores can be used for population analytics. It also does not measure an individual physician's cost of care provision (D); it measures patient-level expected cost burden.

NEW QUESTION # 12
When evaluating a CDI specialist's performance, which of the following expectations is held to the same standard for both inpatient and outpatient initiatives?

A. Query opportunities
B. Review productivity
C. Revenue impact
D. Query compliance

Answer: D

Explanation:
Across both inpatient and outpatient CDI, the single expectation that must remain consistent is query compliance. While productivity targets, the types of query opportunities, and the way "impact" is measured can differ significantly by setting (e.g., DRG/CC-MCC focus in inpatient vs. HCC capture, specificity, and MEAT support in outpatient), the compliance framework for querying does not change. A compliant query must be clinically supported, non-leading, clearly written, and must allow the provider to independently determine the most accurate documentation based on the record. It should include relevant clinical indicators, present reasonable options (including "other"/"unable to determine" when appropriate), and avoid language that appears to request diagnoses for payment purposes. These principles protect documentation integrity, support defensible coding, and reduce audit risk regardless of whether the encounter is hospital-based or ambulatory. By contrast, "review productivity" and "revenue impact" vary widely by program design and setting, and "query opportunities" differ because inpatient vs. outpatient have different reportability rules and documentation drivers. Therefore, query compliance is the metric held to the same standard in both environments.

NEW QUESTION # 13
In February, a patient is diagnosed with prostate cancer, which is classified as HCC 23. In October, the patient is diagnosed with prostate cancer with bone metastases, which is classified as HCC 18. Which of the following is true about the patient's risk score?

A. The risk score will be calculated based upon HCC 18 because it has the highest weight in the hierarchy HCC 23.
B. The risk score will be calculated based upon HCC 23 because it was captured first.
C. The risk score will not be impacted by the presence of HCC 18 or HCC 23 because they are not currently being treated.
D. The risk score will be calculated based upon HCC 18 and HCC 23 because they were both documented and coded in the same calendar year.

Answer: A

Explanation:
In the CMS-HCC model, many related conditions are organized into hierarchies so that only the most severe manifestation within a disease family contributes to the RAF. This prevents double counting when multiple codes describe progressive severity of the same underlying condition. Cancer categories are a common example: a diagnosis reflecting metastatic disease represents substantially higher expected resource utilization than a diagnosis of localized/primary malignancy. In this scenario, the February prostate cancer maps to a lower-severity HCC (HCC 23), while the October documentation of prostate cancer with bone metastases maps to a higher-severity HCC (HCC 18). When both are captured within the applicable period, the hierarchy logic retains the higher-weighted metastatic category and suppresses the lower category. The timing of which was coded first does not control the hierarchy outcome, and both HCCs are not counted together when they fall within the same hierarchical grouping. Therefore, the patient's risk score calculation reflects HCC 18 rather than HCC 23.

NEW QUESTION # 14
Which of the following is the MOST compliant provider query?

A. "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."
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. "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?"
D. "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."

Answer: A

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 # 15
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