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ACDIS CCDS-O Exam Syllabus Topics:

Topic	Details
Topic 1	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 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	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 4	Risk Adjustment Models and Impact of Documentation and Coding: Covers CMS-HCC model fundamentals, RAF scoring, Medicare Advantage payments, hierarchies, disease interactions, and compliant HCC reporting requirements.
Topic 5	Coding and Reporting, the Outpatient Prospective Payment System (OPPS), and provider coding

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ACDIS Certified Clinical Documentation Specialist-Outpatient Sample Questions (Q33-Q38):

NEW QUESTION # 33
Which of the following BEST represents performance metrics important to an outpatient CDI program?

A. Medicare Case Mix Index, aggregate RAF scores, and clinical denial rate
B. Number of secondary diagnoses per claim, aggregate RAF score, and quality indicators
C. Severity of illness, HCC capture rate, and Medicare Case Mix Index
D. HCC capture rate, unspecified code utilization rate, and query response rate

Answer: D

Explanation:
Outpatient CDI performance is best measured by metrics that reflect ambulatory documentation quality, risk-adjustment accuracy, and provider engagement. HCC capture rate is central because outpatient CDI frequently supports risk adjustment (e.g., CMS-HCC/HHS-HCC) and aims to ensure chronic conditions are accurately documented, linked, and reported when they are actively managed. Unspecified code utilization rate is a practical quality metric for provider education because high unspecified use often signals missed clinical specificity (severity, laterality, acuity, manifestations, staging) that can reduce coding accuracy, obscure patient complexity, and weaken data used for benchmarking and quality reporting. Query response rate is also a core operational KPI: it reflects provider participation, workflow effectiveness, and the CDI team's ability to obtain timely clarifications that support compliant coding and complete clinical representation. In contrast, Medicare CMI and severity of illness are predominantly inpatient-focused constructs and are not the primary yardsticks for outpatient CDI program success. While aggregate RAF and quality indicators matter, the best "program performance" set is the one directly tied to outpatient CDI levers: HCC capture, specificity/unspecified reduction, and query responsiveness.

NEW QUESTION # 34
Which of the following best differentiates inpatient from outpatient coding guidelines?

A. Outpatient coding ignores encounter diagnoses
B. Inpatient guidelines emphasize diagnosis sequencing and MS-DRGs
C. Outpatient guidelines focus on principal diagnoses
D. Both use the same guidelines with no differences

Answer: B

Explanation:
A key distinction is that inpatient coding is tightly linked to MS-DRG assignment and inpatient-specific sequencing rules, including selection of the principal diagnosis using the "after study" standard and capture of secondary diagnoses that qualify as complications/comorbidities (CC/MCC) when they meet reporting criteria. This makes diagnosis sequencing and documentation of severity/acuity central to inpatient reimbursement and quality measurement. Outpatient coding does not use MS-DRGs; instead, it typically uses "first-listed" diagnosis concepts for the encounter and assigns ICD-10-CM based on conditions addressed that day, with procedure payment often driven by CPT/HCPCS and, in hospital outpatient departments, packaging/OPPS logic. Therefore, statement A is incorrect (principal diagnosis is not the outpatient focus), C is incorrect (there are meaningful differences), and D is incorrect because outpatient coding absolutely depends on encounter diagnoses being documented and supported. Outpatient CDI education stresses documenting the reason for visit, linking symptoms to confirmed conditions when known, and showing MEAT for chronic conditions so outpatient coding is accurate and defensible.

NEW QUESTION # 35
A 75-year-old with a PMH of chronic foot ulcer, CKD, and depression is seen by his PCP for continued fatigue and decreased urination. Labs drawn on previous day are reviewed. Patient describes extreme fatigue and no motivation. Assessment and plan include: "CKD 3 with renal failure - refer to nephrologist. Chronic nonpressure foot ulcer - home care for wound assessment. Depression - Rx for SSRI." Which of the following are the validated diagnoses that risk adjust and qualify as CMS-HCCs?

A. CKD 3; chronic non-pressure ulcer
B. Renal failure; CKD 3
C. Depression; renal failure
D. Chronic non-pressure ulcer; depression

Answer: A

Explanation:
Under CMS-HCC methodology, risk adjustment is driven by ICD-10-CM diagnoses that map to HCC categories and are supported as active conditions addressed at the encounter. CKD stage 3 is a classic HCC-qualifying chronic condition because it represents ongoing kidney disease severity and expected resource use, and in this note it is actively assessed with labs reviewed and a nephrology referral. A chronic non-pressure foot ulcer is also typically HCC-qualifying when documented as ongoing and requiring management, which is supported here by home care/wound assessment planning. In contrast, "depression" (without specification such as major depressive disorder severity/status) commonly does not qualify for HCC in the way major depressive/bipolar categories do, making it less reliable as a risk-adjusting diagnosis. Likewise, "renal failure" is nonspecific and potentially conflicting with CKD stage 3; CDI best practice would be to clarify acuity/severity (acute kidney injury vs CKD stage vs ESRD) rather than assume "renal failure" as an HCC driver. Therefore, the validated HCC-qualifying pair is CKD 3 and chronic non-pressure ulcer.

NEW QUESTION # 36
Which of the following is a strategy that is often used by ACOs to improve their performance in the Readmission Reduction program?

A. Educate providers about the importance of capturing chronic conditions in documentation.
B. Encourage providers to avoid reporting chronic conditions on subsequent admissions.
C. Flag qualifying patients upon arrival to ED to be placed in observation status vs. admission.
D. Work with IT to increase the unspecified code choices in pick lists in the EHR.

Answer: A

Explanation:
ACOs commonly focus on strengthening documentation and coding of clinically relevant chronic conditions because many quality and utilization comparisons-including readmission-related performance assessments-are influenced by patient complexity and risk adjustment. When chronic diseases and their specificity (e.g., stage, severity, manifestations) are under-documented, attributed patients can appear "healthier" on paper than they truly are, which can worsen an organization's apparent readmission performance when outcomes are compared to an expected benchmark. Provider education that reinforces documenting active conditions that are monitored, evaluated, assessed/addressed, or treated helps ensure an accurate picture of acuity and comorbidity burden. This improves the integrity of risk adjustment inputs and supports fairer benchmarking, while also strengthening medical necessity and continuity-of-care communication across settings. The other choices represent either noncompliant behavior (avoiding condition reporting), poor documentation practice (promoting unspecified codes), or operational maneuvering that may be perceived as gaming rather than a sustainable quality strategy. Therefore, educating providers to capture chronic conditions accurately is the best and most commonly used improvement approach.

NEW QUESTION # 37
Which of the following physician performance metrics BEST illustrates provider engagement with outpatient CDI specialist?

A. Physician RAF scores and RAF capture rates
B. Query response rates and problem list updates
C. Problem list updates and RAF capture rates
D. Physician MIPS scores and query response rates

Answer: B

Explanation:
Provider engagement in an outpatient CDI program is best reflected by measures that show the provider is actively interacting with CDI processes and improving documentation behaviors in real time. Query response rates directly indicate whether the provider is reading and responding to CDI clarifications promptly and consistently, which is a fundamental engagement behavior and a key operational driver of documentation accuracy. Problem list updates further demonstrate sustained engagement because they reflect the provider's willingness to maintain an accurate, current list of active conditions (adding validated diagnoses, removing resolved problems, and updating specificity such as stage, severity, or laterality). Together, these two metrics show both immediate participation (responding to queries) and longer-term adoption of documentation best practices (maintaining the problem list). In contrast, RAF scores and RAF capture rates are influenced by patient complexity, payer mix, and coding capture processes, and may improve even without meaningful provider participation. MIPS scores reflect broader quality program performance and are not specific to CDI-provider interaction. Therefore, query responsiveness plus problem list maintenance most directly measures engagement with outpatient CDI.

NEW QUESTION # 38
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