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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 |
| Real Exam Qty: | 140 questions (120 scored) |
| Available Languages: | English |
| Exam Format: | Multiple-choice, Computer-based exam |
| Passing Score: | 85 out of 120 scored questions |
| Related Certifications: | Certified Clinical Documentation Specialist (CCDS) |
| Recommended Training: | ACDIS Official Certification Resources ACDIS CCDS-O Exam Candidate Handbook (download via official site) |
| 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 # 44
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 # 45
Based on previous documentation, which of the following diagnoses would a CDI specialist be MOST likely to bring to the provider's attention in preparation for an upcoming visit of a 70-year-old patient?
Answer: C
Explanation:
In outpatient CDI, "pre-visit" or prospective preparation focuses on chronic, clinically significant conditions that are likely to remain active and that should be reassessed and documented with clear MEAT support (monitor, evaluate, assess/address, treat) during the upcoming encounter. Epilepsy, chronic heart failure, and Crohn's disease are all long-term conditions that commonly require ongoing medication management, monitoring, and periodic reassessment, making them strong candidates for reminder/education to ensure the provider documents current status (controlled vs uncontrolled, exacerbation, complications, and treatment plan). This also supports accurate risk adjustment because chronic conditions with ongoing impact are the ones expected to be recaptured when addressed. In contrast, option C includes "family history," which is not a current active condition for risk adjustment, and options D includes acute/self-limited problems (syncope episode, pharyngitis) that are less appropriate as pre-visit chronic-condition prompts. Option B mixes chronic disease with items that may be historical or encounter-specific (compression fracture timing/status), making it less consistently targetable than option A.
NEW QUESTION # 46
A patient with a PMH of DM, GERD, and HTN is seen in the clinic with complaints of stuffy nose, fever, and feeling tired for the past four days. The patient's medication list includes SSI, Prilosec, and Diovan. The provider documented: "Congestion, fever, malaise, DM, GERD, HTN. Continue OTC medications for congestion and fever. Rest. Return to the clinic in one week if symptoms persist." Which of the following ICD-10-CM guidelines BEST applies to how this scenario should be coded?
Answer: A
Explanation:
In the outpatient setting, when the provider does not document a definitive diagnosis for the acute complaint (e.g., influenza, sinusitis, URI), ICD-10-CM guidance directs coders to report the signs and symptoms that are documented and addressed. Here, the clinician documents congestion, fever, and malaise and provides treatment instructions for those symptoms (OTC meds, rest, follow-up). That makes the symptom codes the most appropriate representation of the reason for the encounter. Outpatient CDI principles further emphasize that chronic conditions like DM, GERD, and HTN should only be coded when the documentation shows they were evaluated, monitored, assessed/managed, or treated during the visit (e.g., status, control, medication adjustment, related testing, counseling). In this note, the plan targets only the acute symptoms and does not demonstrate active management of the chronic conditions beyond listing history/medications. Therefore, the guideline most directly applicable to correct coding of the encounter is codes that describe symptoms and signs.
NEW QUESTION # 47
A patient is seen by an endocrinologist to manage his poorly controlled diabetes with peripheral neuropathy and claudication. The patient has had several toes amputated in prior years and currently has a non-healing ulcer on the left foot. The patient's additional chronic conditions consist of the following: HF, CAD, COPD, history of prostate cancer, arthritis, depression, and sleep apnea. Which of the following chronic conditions should the CDI specialist consider for future education regarding RAF impact with the endocrinologist?
Answer: C
Explanation:
For RAF impact in the CMS-HCC model, the most valuable provider education targets are conditions that (1) map to HCCs or interact with HCC hierarchies, and (2) are clearly within the specialist's scope to assess and manage during visits. In this scenario, the endocrinologist is actively treating diabetes and its complications. Diabetes with peripheral neuropathy/vascular disease plus an active non-healing foot ulcer reflects significant diabetic disease burden and often supports additional required coding (e.g., diabetes complication code plus a separate site/severity ulcer code). The history of toe amputations is also important because amputation status can represent ongoing complexity, affects care planning (risk of recurrent ulcer/infection), and may contribute to risk capture depending on the model and associated complications. By contrast, CAD/COPD/HF may not be evaluated by the endocrinologist at the visit, "A1C" is a lab value (not a diagnosis), and "history of prostate cancer" generally does not risk-adjust like active malignancy. Therefore, educating on documenting diabetes, amputation status, and ulcer details best supports RAF accuracy.
NEW QUESTION # 48
Provider documentation states: "Patient is here for follow-up for multiple chronic conditions, including COPD, HTN, DM, and alcohol abuse. She admits to drinking more than she has in the past, starting in the early morning and consumes at least a pint a day. Her BP today is elevated at 165/89. Discussed medications and diet. As she continues to be dependent on alcohol, several treatment options were offered. She stated she would think about it." Which of the following groups of diagnoses is supported by the clinical indicators described?
Answer: C
Explanation:
The clinical indicators strongly support alcohol dependence, not merely alcohol "use" or "abuse." The patient reports heavy, compulsive intake (early-morning drinking and at least a pint daily), and the provider explicitly documents that she "continues to be dependent on alcohol" and discusses treatment options-this aligns with a dependence-level disorder being addressed. Hypertension is also supported because the BP is elevated (165/89) and the provider documents management activity (medications and diet counseling), meeting encounter relevance/reportability expectations. Diabetes is listed among chronic conditions, but the scenario provides no indicators of complications (no neuropathy, CKD, ulcers, retinopathy, etc.), so the supported choice is DM type 2 without complications rather than "with complications." Although COPD is listed in the "including" statement, no COPD-specific assessment/monitoring/treatment is described in the indicators provided, so the best-supported grouped option focuses on the conditions with clear supporting indicators and management in the note: DM2 without complications, HTN, and alcohol dependence.
NEW QUESTION # 49
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