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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: | Multiple-choice, Computer-based exam |
| Available Languages: | English |
| Real Exam Qty: | 140 questions (120 scored) |
| Passing Score: | 85 out of 120 scored questions |
| Recommended Training: | ACDIS CCDS-O Exam Candidate Handbook (download via official site) ACDIS Official Certification Resources |
| Exam Registration: | CCDS-O Certification Information ACDIS Certification Page |
| 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 # 17
What diagnoses are included in code category N18, chronic kidney disease?
Answer: C
Explanation:
ICD-10-CM category N18 (Chronic kidney disease) is used to report CKD by stage, including stage-based descriptors and end stage renal disease (ESRD). Within N18, codes identify CKD stage 1 through stage 5, ESRD (stage 5D), and CKD unspecified. Outpatient CDI review focuses on ensuring providers document the stage (often supported by eGFR trends) because stage drives correct code selection and accurately reflects disease severity for risk, quality, and medical necessity. Options that include dialysis are not part of N18 itself; dialysis status and encounter codes are reported elsewhere (e.g., dialysis dependence/status codes), not as N18 category diagnoses. AKI (acute kidney injury) and ATN (acute tubular necrosis) are acute renal conditions and are coded outside N18. Likewise, polycystic kidney disease and "uremia" are separate diagnoses with their own code categories. Therefore, the set that correctly matches what N18 represents is CKD stage-based diagnoses such as CKD stage 3, more advanced/severe CKD stages, and ESRD.
NEW QUESTION # 18
A patient is seen at the clinic for a fever, and the provider documents possible Zika virus. A CDI specialist reviews the record and notes that a positive serology test indicates the Zika virus. Which of the following should the CDI specialist do NEXT?
Answer: C
Explanation:
In the outpatient setting, diagnoses documented as uncertain (e.g., "possible," "probable," "suspected," "rule out") are generally not coded as confirmed conditions; instead, coding is based on confirmed diagnoses or, when not confirmed, the presenting signs/symptoms. Here, the provider documented only "possible Zika," which is not a confirmed diagnosis for outpatient reporting. Even though the CDI specialist sees a positive serology result, lab data alone does not replace provider diagnostic confirmation in the assessment/plan. The appropriate next step is to query the provider to confirm whether Zika is the established diagnosis based on the positive test (and whether it is clinically addressed during the encounter). If confirmed, Zika can be coded appropriately and sequenced based on the reason for the visit; if not confirmed or still under evaluation, the symptom (fever) remains first-listed. Option B is incorrect because coders do not "code the result" of a serology test as a diagnosis; they code the condition the test supports once clinically confirmed.
NEW QUESTION # 19
Which of the following conditions or findings supports a diagnosis of diabetes?
Answer: C
Explanation:
In outpatient clinical documentation and chart review, diabetes can be supported by recognized diagnostic thresholds. An HbA1c value reflects average blood glucose over approximately the prior 2-3 months and is commonly used to diagnose and monitor diabetes. An HbA1c ≥ 6.5% (when confirmed per clinical practice standards and interpreted in the appropriate clinical context) supports a diagnosis of diabetes; therefore an HbA1c of 7.0% clearly meets the threshold and supports diabetes. By comparison, a 2-hour OGTT value of 90 mg/dL is normal and does not support diabetes (diabetes is typically supported when the 2-hour value is ≥ 200 mg/dL). Hypoglycemia is low blood glucose and is not diagnostic of diabetes; it may occur in diabetics due to treatment but can also occur in non-diabetics for many reasons. A fasting glucose of 100 mg/dL is at most borderline/prediabetes range and does not meet diagnostic criteria for diabetes (diabetes is supported at ≥ 126 mg/dL).
NEW QUESTION # 20
A female patient who underwent total hip replacement 2 weeks ago is in for a follow-up visit with her PCP. The visit note states: "Patient complains of fatigue and lethargy. Hgb on discharge was 10.4gm/dL - now is 8.6 gm/dL. Will start FeSO4 325mg po daily with food. Repeat H/H in 2 weeks. She has return visit with Ortho then." Which of the following is the BEST course of action for the CDI specialist?
Answer: A
Explanation:
Outpatient CDI practice supports accurate, provider-validated diagnoses; CDI should not "diagnose," direct the provider to add a specific condition, or independently add diagnoses to the claim. Here, the documentation shows clinical indicators (fatigue/lethargy and hemoglobin drop from 10.4 to 8.6) and a treatment plan (oral iron and repeat H/H), but the provider has not stated a definitive diagnosis such as postoperative anemia, iron deficiency anemia, acute blood loss anemia, or anemia due to chronic disease. The best CDI action is to issue a compliant query that summarizes the relevant indicators and treatment and asks the provider to document the appropriate diagnosis and etiology, if clinically supported, and to link it to the plan of care. Option A is inappropriate because it leads the provider toward a specific diagnosis. Option D is noncompliant because coding must follow documented provider diagnoses. Option B may be a reasonable internal check, but it does not resolve the documentation gap.
NEW QUESTION # 21
In which of the following ways does payment determination (risk score calculation) differ between HHS-HCCs and CMS-HCCs?
Answer: A
Explanation:
A key ambulatory CDI distinction between the two major risk models is timing. The HHS-HCC model (used for ACA Marketplace risk adjustment) is commonly described as a concurrent model: it uses the enrollee's demographics and diagnoses from the same benefit year to reflect morbidity and support that year's risk transfer/payment balancing. In contrast, the CMS-HCC model (commonly applied in Medicare Advantage) is prospective: conditions documented and coded in the prior data collection year are used to predict expected cost for the following payment year. From an outpatient CDI perspective, this timing difference affects operational priorities. For CMS-HCC, accurate annual capture and recapture of active chronic conditions is essential because last year's documented conditions drive next year's risk score and revenue. For HHS-HCC, complete documentation and coding during the current year impacts the current year's risk measurement. Options referencing CPT codes are not correct for the core HCC risk score calculation, which is driven by demographics and ICD diagnosis reporting mapped to HCC categories.
NEW QUESTION # 22
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