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ACDIS CCDS-O Exam Syllabus Topics:

TopicDetails
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
  • 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
  • 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 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.

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The ITCertMagic ACDIS CCDS-O online practice exam is browser-based and accessible via any browser including Firefox, MS Edge, Safari, Opera, Chrome, and Internet Explorer. This format is also embedded with multiple ACDIS CCDS-O Practice Exam and all specs of the desktop software. You can easily adjust time and questions in all Certified Clinical Documentation Specialist-Outpatient online Practice Exam.

ACDIS Certified Clinical Documentation Specialist-Outpatient Sample Questions (Q22-Q27):

NEW QUESTION # 22
Which of the following conditions or findings supports a diagnosis of diabetes?

Answer: C

Explanation:
In outpatient clinical documentation and chart review, diabetes can be supported by recognized diagnostic thresholds. An HbA1c value reflects average blood glucose over approximately the prior 2-3 months and is commonly used to diagnose and monitor diabetes. An HbA1c ≥ 6.5% (when confirmed per clinical practice standards and interpreted in the appropriate clinical context) supports a diagnosis of diabetes; therefore an HbA1c of 7.0% clearly meets the threshold and supports diabetes. By comparison, a 2-hour OGTT value of 90 mg/dL is normal and does not support diabetes (diabetes is typically supported when the 2-hour value is ≥ 200 mg/dL). Hypoglycemia is low blood glucose and is not diagnostic of diabetes; it may occur in diabetics due to treatment but can also occur in non-diabetics for many reasons. A fasting glucose of 100 mg/dL is at most borderline/prediabetes range and does not meet diagnostic criteria for diabetes (diabetes is supported at ≥ 126 mg/dL).


NEW QUESTION # 23
A patient presents to the clinic for follow up of type 2 diabetes. The patient is also noted to have peripheral neuropathy. The patient has COPD and is found to have no recent exacerbations. The patient also has a history of depression, reported as stable. Which of the following CMS-HCCs will be captured for this visit?
HCC 17: Diabetes with Acute Complications
HCC 18: Diabetes with Chronic Complications
HCC 19: Diabetes without Complications
HCC 58: Major Depressive, Bipolar and Paranoid Disorders
HCC 111: Chronic Obstructive Pulmonary Disease

Answer: D

Explanation:
In the CMS-HCC model, diabetes categories are hierarchical, meaning you capture the highest supported diabetes HCC for the year, not multiple diabetes HCCs simultaneously. Type 2 diabetes with peripheral neuropathy represents a chronic diabetic complication, so it maps to HCC 18 (Diabetes with Chronic Complications) rather than HCC 19 (without complications) or HCC 17 (acute complications). COPD is documented as present and clinically relevant (even without an exacerbation) and therefore maps to HCC 111 (Chronic Obstructive Pulmonary Disease) when it is assessed/managed as part of the visit. "History of depression, stable" does not necessarily meet the threshold for HCC 58, which is reserved for specific serious psychiatric diagnoses (e.g., major depressive disorder, bipolar disorder, paranoid disorders). A general "depression" history, especially if not specified as major depressive disorder and not actively addressed, often will not support HCC 58 capture. Therefore, the visit captures HCC 18 and HCC 111 only.


NEW QUESTION # 24
Which diagnosis and treatment plan may generate a query?

Answer: D

Explanation:
Outpatient CDI queries are most commonly triggered when there is a disconnect between the documented diagnosis and the documented treatment plan, suggesting that the clinician may be managing an additional condition that is not clearly stated, or that the diagnosis is inaccurately documented. Options A and B reflect typical, clinically aligned management: luteinizing hormone-releasing hormone therapy is a standard treatment pathway for prostate carcinoma, and amiodarone is a recognized antiarrhythmic used in atrial fibrillation management in appropriate circumstances. Option C can also be clinically consistent because parenteral nutrition is often used when malnutrition is present and the patient cannot meet nutritional needs enterally. Option D is the outlier: "immunotherapy" is not a standard treatment for severe major depressive disorder and more commonly aligns with oncology or certain immune-mediated diseases. This mismatch would appropriately prompt a query to clarify the actual condition being treated (e.g., an active malignancy) or to confirm whether "immunotherapy" refers to something else (such as allergy immunotherapy) and whether depression is the correct, visit-relevant diagnosis being addressed.


NEW QUESTION # 25
Which of the following best differentiates inpatient from outpatient coding guidelines?

Answer: A

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 # 26
Upon review of payer data, a decrease in RAF scores for the organization is noted. After reviewing internal metrics, a CDI specialist notes an increase in the volume of HCC queries across the organization, with accurate coding confirmed. Which of the following is the MOST plausible explanation for these findings?

Answer: C

Explanation:
When internal CDI metrics show increased HCC-related querying and coding accuracy is confirmed, you would typically expect payer RAF outputs to stabilize or improve-assuming the payer receives and processes the same diagnosis data. A payer-reported RAF decrease despite accurate internal capture most strongly suggests a break in the data flow between the organization and the payer. In outpatient risk adjustment, RAF depends on documented, supported diagnoses being correctly coded and then successfully transmitted on the encounter/claim to the payer's risk-adjustment ingestion process. If certain diagnoses are dropped (claim edits, interface mapping issues, encounter rejection, late submissions, or incomplete encounter files), the payer's dataset will under-represent HCCs and RAF will fall even though internal coding looks correct. CPT visibility (B) generally affects utilization/fee-for-service payment and analytics, not HCC-based RAF. Compliant queries (C) describe process quality but don't explain a payer-side RAF decline. A local "model not updated" (D) wouldn't reduce payer-calculated RAF if the payer is applying its own current model to received diagnoses.


NEW QUESTION # 27
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