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ACDIS CCDS-O Exam Syllabus Topics:

Topic
Details

Topic 1

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 2

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 3

Healthcare regulations, reimbursement, and documentation requirements related to the Official Guidelines for

Topic 4

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 5

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 6

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.

ACDIS Certified Clinical Documentation Specialist-Outpatient Sample Questions (Q114-Q119):

NEW QUESTION # 114
In which of the following ways does payment determination (risk score calculation) differ between HHS-HCCs and CMS-HCCs?

A. HHS-HCCs use current ICD-10-CM and CPT codes to predict the current year's spending.
B. HHS-HCCs use the current year's demographics/diagnoses to predict the current year's spending.
C. HHS-HCCs use the previous year's ICD-10-CM and CPT codes to predict the next year's spending.
D. HHS-HCCs use the previous year's demographics/diagnoses to predict the next year's spending.

Answer: B

Explanation:
A key ambulatory CDI distinction between the two major risk models is timing. The HHS-HCC model (used for ACA Marketplace risk adjustment) is commonly described as a concurrent model: it uses the enrollee's demographics and diagnoses from the same benefit year to reflect morbidity and support that year's risk transfer/payment balancing. In contrast, the CMS-HCC model (commonly applied in Medicare Advantage) is prospective: conditions documented and coded in the prior data collection year are used to predict expected cost for the following payment year. From an outpatient CDI perspective, this timing difference affects operational priorities. For CMS-HCC, accurate annual capture and recapture of active chronic conditions is essential because last year's documented conditions drive next year's risk score and revenue. For HHS-HCC, complete documentation and coding during the current year impacts the current year's risk measurement. Options referencing CPT codes are not correct for the core HCC risk score calculation, which is driven by demographics and ICD diagnosis reporting mapped to HCC categories.

NEW QUESTION # 115
Which of the following BEST describes a Stage 3 pressure ulcer?

A. Abrasion, blister, partial thickness skin loss involving epidermis and/or dermis
B. Pre-ulcer skin changes limited to persistent focal edema
C. Full thickness skin loss involving damage or necrosis of subcutaneous tissue
D. Necrosis of soft tissues through to underlying muscle, tendon, or bone

Answer: C

Explanation:
Stage 3 pressure ulcers are defined by full-thickness skin loss where the injury extends through the dermis and involves damage or necrosis of subcutaneous tissue. Clinically, the ulcer may present as a deep crater and can include undermining or tunneling, but the key boundary is that bone, tendon, and muscle are not exposed. That deeper involvement (exposed muscle/tendon/bone) is characteristic of Stage 4, making option C incorrect. Option D describes partial-thickness loss, which aligns with Stage 2 (epidermis/dermis involvement such as abrasion or blister). Option A reflects early skin changes that correspond more closely to Stage 1 (intact skin with non-blanchable erythema and possible localized edema/induration). In outpatient CDI chart review, accurately distinguishing Stage 3 from Stage 2 and Stage 4 is essential because staging drives severity capture, care planning (wound care interventions, debridement considerations), and quality reporting. Documentation should clearly support "full thickness," the tissue layers involved, and the absence of exposed bone/tendon/muscle.

NEW QUESTION # 116
Which of the following conditions is commonly treated with the medication sertraline?

A. Heart failure
B. Asthma
C. Schizophrenia
D. Depression

Answer: D

Explanation:
Sertraline is a selective serotonin reuptake inhibitor (SSRI) most commonly used to treat depressive disorders and several anxiety-related conditions. In outpatient chart review, recognizing medication-condition relationships supports accurate problem list maintenance and compliant diagnosis reporting, but the diagnosis must still be clearly documented as assessed/managed at the encounter. Depression is the best match because SSRIs like sertraline are first-line pharmacologic therapy for major depressive disorder and are frequently continued long-term with monitoring for symptom control, side effects, and functional status. Schizophrenia is primarily treated with antipsychotic medications; sertraline may be used only as an adjunct if a comorbid depressive or anxiety disorder is present, so it is not the common primary treatment. Asthma management centers on bronchodilators and inhaled corticosteroids, not SSRIs. Heart failure therapy involves guideline-directed cardiac medications (e.g., beta-blockers, ACE inhibitors/ARNI, diuretics), and sertraline is not a standard heart failure treatment. Outpatient CDI education emphasizes documenting the specific mental health diagnosis, current status (stable/worsening), and treatment plan to support coding.

NEW QUESTION # 117
A 76-year-old patient presents for a wellness visit. The patient's vitals are BP 120/80, T 98.7, R 19, and there are no abnormal findings in the exam. The patient has COPD, home oxygen, anemia, hypertension, diabetes, fatigue, and weakness. The patient's medications are called into the pharmacy and home health resource of choice. Which of the following is the BEST query option?

A. Acute blood loss anemia
B. Peripheral neuropathy
C. Chronic respiratory failure
D. CKD

Answer: C

Explanation:
The best query is chronic respiratory failure because home oxygen is a strong clinical indicator that often reflects an underlying chronic hypoxemic condition beyond uncomplicated COPD. Outpatient CDI guidance stresses that queries should be driven by present clinical indicators in the note and should seek clarification that impacts accurate diagnosis capture and ongoing care. Here, the provider documents COPD plus home oxygen and is arranging continued services (medication management and home health), which supports asking whether the patient has a reportable condition such as chronic respiratory failure with hypoxia (or COPD with chronic hypoxemia) and whether it is being monitored/managed. The other options lack support: acute blood loss anemia has no bleeding, hemodynamic instability, or acute findings; peripheral neuropathy is not assessed or described despite diabetes; and CKD has no labs, staging, history, or assessment. A compliant query would be non-leading and include the indicator (home O₂) and request the most accurate diagnosis and specificity/status.

NEW QUESTION # 118
A morbidly obese patient with a BMI of 45 who is reliant on CPAP at night is likely to have which of the following conditions?

A. Pulmonary edema
B. Heart failure
C. Alveolar hypoventilation
D. Essential hypertension

Answer: C

Explanation:
Nightly reliance on CPAP in a morbidly obese patient most strongly points to sleep-disordered breathing, and in the context of severe obesity (BMI 45), it raises concern for obesity hypoventilation syndrome (OHS), which is characterized by alveolar hypoventilation (chronic hypoventilation with hypercapnia) that is not fully explained by other pulmonary or neuromuscular causes. While CPAP is commonly prescribed for obstructive sleep apnea, severe obesity increases the likelihood of associated hypoventilation physiology; in outpatient CDI review, this becomes a documentation opportunity to ensure the provider specifies whether the patient has OSA alone versus OSA with OHS/alveolar hypoventilation, because the latter reflects higher clinical complexity and requires clear monitoring/management (e.g., ABGs or bicarbonate trends, symptoms of hypoventilation, adherence, need for BiPAP). Heart failure and pulmonary edema are not implied by CPAP use, and essential hypertension is common in obesity but not the condition most specifically linked to CPAP dependence. Therefore, alveolar hypoventilation is the best supported answer.

NEW QUESTION # 119
......

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