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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 |
| Exam Format: | Multiple-choice, Computer-based exam |
| Related Certifications: | Certified Clinical Documentation Specialist (CCDS) |
| 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 # 65
A patient presents to the clinic with indwelling Foley catheter, symptoms of fatigue, and low back pain with BPH. Labs reveal WBC 20, and the urine culture is positive for E. coli. Prescription antibiotics are ordered for a UTI. Which of the following is the BEST query opportunity?
Answer: A
Explanation:
The strongest CDI query opportunity is clarifying whether the UTI is catheter-associated. The patient has an indwelling Foley catheter, significant leukocytosis (WBC 20), a positive urine culture for E. coli, and is being treated with antibiotics for UTI-these indicators raise a clear question about the etiology of infection and whether it is related to the urinary catheter. In outpatient CDI practice, linking the infection to a device (when clinically supported) improves documentation accuracy, supports correct code assignment, and has important quality and compliance implications because catheter-associated UTIs are captured differently than uncomplicated UTIs. By comparison, querying the "etiology of BPH" is not supported as an immediate gap (BPH is already stated), and the "etiology of low back pain" is less directly tied to the documented treatment focus (UTI management). "Leukocytosis" is a lab finding that is already objectively supported and often represents a symptom/abnormal result rather than the principal clarification needed. Therefore, confirming whether the UTI is related to the Foley catheter is the best, most clinically anchored query.
NEW QUESTION # 66
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?
Answer: B
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 # 67
PCP notes describe declining renal function with creatinine trending upward over the last 12 months. Nephrology consult ordered. Which of the following diagnostic tests could support a query to identify status of the patient's baseline renal function?
Answer: A
Explanation:
To establish and query for a patient's baseline renal function in the outpatient setting, eGFR is the most direct and standardized measure because it estimates kidney filtration capacity using serum creatinine (and patient factors such as age/sex, and sometimes race depending on the equation used). Outpatient CDI concepts emphasize that chronic kidney disease staging is based primarily on eGFR categories (G1-G5) and persistence over time, making eGFR trends particularly useful for determining whether the patient has CKD, whether it is worsening, and what stage should be documented. Serum creatinine alone can suggest decline but does not translate cleanly to CKD stage without calculating eGFR and considering patient characteristics. BUN is influenced by hydration status, protein intake, bleeding, and catabolic states, so it is less reliable for baseline kidney function assessment. ACR is important for detecting albuminuria and refining CKD classification/risk stratification, but it complements eGFR rather than replacing it as the primary indicator of baseline filtration function.
NEW QUESTION # 68
In review of a clinic record, a CDI specialist notes the provider has directly copied and pasted a previous inpatient problem list into the current ambulatory visit note. Which of the following is the CDI specialist's BEST course of action?
Answer: B
Explanation:
Copy-and-paste of an inpatient problem list into an outpatient note creates significant documentation integrity risks: outdated diagnoses may be carried forward, resolved conditions may appear active, and the note may not clearly show which problems were actually evaluated or managed during the current encounter. Outpatient CDI best practice is not to assume relevance (eliminating D) and not to reflexively query every listed diagnosis (B), which can be burdensome, non-targeted, and may lead to "query fatigue." Likewise, blanket instruction to "not code" anything pasted (A) is not appropriate because some conditions may still be active and reportable if the provider documents assessment/management (e.g., monitoring, evaluation, addressing, or treatment). The most effective and sustainable action is provider education: explain why indiscriminate copy-forward threatens accuracy, compliance, medical necessity support, quality reporting, and risk adjustment validity; reinforce documenting current status and care provided for each active condition; and encourage updating the problem list and assessment to reflect what is truly addressed at the visit. Targeted queries can still be used when specific contradictions or high-impact ambiguities are identified.
NEW QUESTION # 69
During a PCP visit, a provider notes a patient's history of pathological fracture of the thoracic spine related to osteoporosis. Documentation states: "Decreased muscle mass and significant weight loss in the last six months." Which of the following should the CDI specialist query for?
Answer: C
Explanation:
The documentation "decreased muscle mass and significant weight loss in the last six months" raises a strong clinical indicator for a nutrition-related condition (e.g., malnutrition, cachexia, or other clinically significant weight loss) that should be clarified by the provider. In outpatient CDI practice, ACDIS-based guidance emphasizes querying when there are objective or clearly stated indicators suggesting an additional diagnosis that is clinically relevant, affects management, or reflects patient complexity. Malnutrition is particularly important because it can explain functional decline, frailty, and increased risk of falls/fractures, and it often changes the care plan (dietary counseling, nutrition referral, supplementation, labs, monitoring). While "degree of muscle atrophy" and "acuity of the fracture" could matter in other contexts, the note explicitly highlights a systemic decline over six months rather than an acute fracture issue. "Type of osteoporosis" is relevant for specificity, but the new, clinically significant clue here is unintended weight loss with muscle wasting-making malnutrition the most appropriate clarification opportunity.
NEW QUESTION # 70
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