最新CCDS-O題庫 &最新CCDS-O考題

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ACDIS CCDS-O Exam Syllabus Topics:

Section	Objectives
Topic 1: Healthcare Regulations and Reimbursement	- Medicare OPPS Payment Logic 1. Status Indicators 2. APC Classification - Risk Adjustment Models 1. RxHCC 2. HCC (Hierarchical Condition Categories)
Topic 2: Clinical Documentation Integrity (CDI) Program Operations	- Provider Engagement and Education 1. Feedback Mechanisms - Query Process 1. Compliance and Best Practices 2. Query Types
Topic 3: Disease Processes and Clinical Concepts	- Common Disease Categories 1. Endocrine, Nutritional, and Metabolic Diseases 2. Respiratory System 3. Circulatory System 4. Neoplasms - Anatomy and Physiology 1. Pharmacology 2. Pathophysiology
Topic 4: Quality Initiatives	- HEDIS Measures - Patient Safety

>> 最新CCDS-O題庫 <<

真實的最新CCDS-O題庫＆準確的ACDIS認證培訓 - 有效的ACDIS Certified Clinical Documentation Specialist-Outpatient

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最新的 Clinical Documentation Specialist CCDS-O 免費考試真題 (Q36-Q41):

問題 #36
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 the sleep apnea
B. Status of ostomy
C. Status of colon cancer
D. Status of the COPD

答案：C

解題說明：
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.

問題 #37
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 chronic diastolic heart failure documented in her problem list. Can you please add this diagnosis to your progress note from her office visit?"
C. "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."
D. "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?"

答案：C

解題說明：
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.

問題 #38
Which of the following conclusions can be drawn from the impact of a CDI program on Clinic A using the table below?

A. Providers are more engaged in 2023 than in 2022.
B. Treated a more complex population than any of the other clinics in 2023.
C. Consistently captured a higher RAF percentage each month in 2023 than in 2022.
D. Served a sicker population in 2023 than in 2022.

答案：C

解題說明：
The only conclusion that is directly supported by the table is that Clinic A's percent RAF captured is higher in every month of 2023 compared with the corresponding month in 2022. The monthly values rise year-over-year (e.g., January 21% vs 17%, February 33% vs 25%, and continuing through December 84% vs 76%), showing a consistent improvement pattern across the entire calendar year. In outpatient CDI and risk adjustment work, "RAF capture" is commonly used as a performance indicator reflecting how completely documented and coded risk-adjusting conditions (e.g., HCC-supported diagnoses) are being captured within the measurement period. However, the table does not prove why the improvement occurred. It cannot confirm provider engagement (A) without workflow/participation data, cannot compare to other clinics (B) because no other clinic data are shown, and cannot establish that the population was sicker (C) because RAF capture measures documentation/coding completeness relative to opportunity, not inherent patient acuity. Therefore, D is the verified conclusion.

問題 #39
Which of the following is a form of a cardiac condition that may be treated with a beta-blocker?

A. Coronary artery disease
B. Third degree heart block
C. Cardiomyopathy
D. Sinus bradycardia

答案：A

解題說明：
Beta-blockers are commonly used in the management of coronary artery disease (CAD) because they lower heart rate, decrease myocardial contractility, and reduce oxygen demand-key goals in treating stable angina and in secondary prevention after myocardial infarction. In outpatient chart review, ACDIS-focused clinical documentation education emphasizes linking the medication to the condition being managed (e.g., "CAD with angina-on metoprolol for symptom control" or "history of MI-on beta-blocker for secondary prevention") to support accurate diagnosis reporting and demonstrate ongoing assessment and treatment. By contrast, third-degree (complete) heart block and sinus bradycardia are conditions where beta-blockers are typically avoided or used only with extreme caution because they can worsen conduction delay and slow the heart rate further. Cardiomyopathy can sometimes be treated with certain evidence-based beta-blockers when the clinical context is systolic heart failure, but the option most broadly and reliably associated with beta-blocker treatment in standard outpatient practice and documentation is CAD.

問題 #40
Which of the following acronyms is often used in considering reportability of conditions?

A. MEAT
B. OPPS
C. RADV
D. MACRA

答案：A

解題說明：
In outpatient CDI, MEAT is a commonly taught framework used to determine whether a condition is sufficiently supported as reportable for a specific encounter. MEAT stands for Monitor, Evaluate, Assess/Address, and Treat. The concept is that diagnoses should not simply be copied forward on a problem list; they should be tied to provider work and clinical relevance during the visit. "Monitor" includes reviewing status, trends, or test results related to the condition. "Evaluate" includes ordering or interpreting studies, considering disease progression, or documenting response to therapy. "Assess/Address" includes documenting stability, exacerbation, or risk and making a plan (education, counseling, referrals). "Treat" includes medications, procedures, or other therapeutic interventions. Using MEAT helps CDI staff educate providers to document the current status and management of chronic diseases, supports accurate coding and risk adjustment, and reduces denials by showing medical necessity. OPPS, MACRA, and RADV are important regulatory/payment terms, but they are not the standard acronym used to assess encounter-level reportability.

問題 #41
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