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ACDIS CCDS-O Exam Syllabus Topics:

Topic	Details
Topic 1	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 2	Coding and Reporting, the Outpatient Prospective Payment System (OPPS), and provider coding
Topic 3	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 4	Quality, Regulatory, and Health Initiatives: Covers population health, MSSP, ACO models, MACRA MIPS, compliant query development, RADV audits, OIG compliance, problem list maintenance, and HIPAA requirements in outpatient CDI.
Topic 5	Healthcare regulations, reimbursement, and documentation requirements related to the Official Guidelines for
Topic 6	and billing: Covers Official Coding Guidelines, OPPS reimbursement (APCs), and professional billing concepts including CPT E M codes and Medicare Physician Fee Schedule documentation.

Reference: https://acdis.org/sites/acdis/files/Handbook_CCDS_CCDS-O.pdf

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ACDIS Certified Clinical Documentation Specialist-Outpatient Sample Questions:

Question #1

The majority of E/M services are based on which of the following criteria?

A. New/established, site of service, and time
B. New/established, physician specialty, and level of service
C. New/established, level of service, and age of patient
D. New/established, site of service, and level of service

Reveal Solution Discussion 0

Correct Answer: D 🗳️

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Question #2

An elderly patient with a PMH of CHF, DM type 1, arthritis, and HTN is seen in the clinic for a follow-up appointment after a recent hospitalization. After an evaluation of the patient's current health status, the provider documents the following: "HFrEF: lungs clear, no edema, continue meds. DM: no changes to insulin pump. Arthritis: asymptomatic joint destruction. HTN: BP stable. Continue meds." Which of the following is the clarification opportunity in the above scenario?

A. The insulin status
B. The type and severity of heart failure
C. A link between the DM and arthritis
D. A link between HTN and heart failure

Reveal Solution Discussion 0

Correct Answer: D 🗳️

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Question #3

A patient presents to the PCP's office with LLE edema and pain for 3 days. The problem list indicates morbid obesity and a history of DVT. Vital signs are T 37.9, P 76, R 12, BP 142/88, BMI 46. Documentation states: "Patient presents with LLE edema, increased pain, and hx of DVT. Sedentary lifestyle and contraindications to anticoagulation therapy. LLE warm to touch, 3+ edema from ankle to knee. Pedal pulses 2+ on L and 3+ on R." Doppler exam indicates DVT. The PCP should be queried for which of the following diagnoses?

A. Hypertensive urgency and status of the DVT
B. Morbid obesity and status of the DVT
C. Hypercoagulability and morbid obesity
D. Hypercoagulability and hypertensive urgency

Reveal Solution Discussion 0

Correct Answer: B 🗳️

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Question #4

A patient presents with pulmonary rales, pulmonary edema found on chest x-ray, and bilateral ankle edema. Which of the following conditions will the provider MOST likely evaluate further?