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ACDIS CCDS-O Exam Syllabus Topics:

Topic
Details

Topic 1

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 2

Coding and Reporting, the Outpatient Prospective Payment System (OPPS), and provider coding

Topic 3

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 4

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

Topic 5

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.

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For added reassurance, we also provide you with up to 1 year of free ACDIS Dumps updates and a free demo version of the actual product so that you can verify its validity before purchasing. The key to passing the ACDIS CCDS-O exam on the first try is vigorous Certified Clinical Documentation Specialist-Outpatient (CCDS-O) practice. And that's exactly what you'll get when you prepare from our Certified Clinical Documentation Specialist-Outpatient (CCDS-O) practice material. Each format of our CCDS-O study material excels in its own way and serves to improve your skills and gives you an inside-out understanding of each exam topic.

ACDIS Certified Clinical Documentation Specialist-Outpatient Sample Questions (Q21-Q26):

NEW QUESTION # 21
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?

A. Diabetes mellitus, syncopal episode, and pharyngitis
B. Epilepsy, chronic heart failure, and Crohn's disease
C. Chronic obstructive lung disease, T3 compression fracture, and s/p kidney transplant
D. Family history of lung cancer, atrial fibrillation, and sickle cell

Answer: B

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 # 22
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?

A. Query the provider for each of the conditions on the problem list.
B. Assume the conditions are all relevant for this visit.
C. Do not code conditions that were pasted from the problem list.
D. Educate the provider regarding the concerns with copying and pasting this list.

Answer: D

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 # 23
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?

A. Query the provider to code the result of the serology test.
B. Code the Zika virus as the reason for the visit.
C. Code the fever as the first-listed diagnosis and Zika virus as secondary.
D. Query the provider to confirm the diagnosis of Zika.

Answer: D

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 # 24
Which of the following diabetic complications requires the assignment of a combination code plus the code for the specific complication?

A. Nephropathy
B. Osteomyelitis
C. Retinopathy
D. Dermatitis

Answer: B

Explanation:
In ICD-10-CM diabetes coding (as reinforced in outpatient CDI education), some diabetes manifestations are fully captured by a single diabetes "combination" code, while others require a diabetes complication code plus an additional code to identify the specific manifestation. Diabetic nephropathy and many forms of diabetic retinopathy are commonly represented by diabetes combination codes that already describe the manifestation with built-in specificity options (e.g., diabetes with nephropathy; diabetes with retinopathy with/without macular edema and severity). Osteomyelitis, however, is typically captured using a diabetes code such as "diabetes with other specified complication" (e.g., E11.69) to establish the linkage to diabetes and an additional code from the osteomyelitis category (e.g., M86.-) to specify the site, acuity, and type of osteomyelitis. From a chart review standpoint, CDI often queries to confirm the causal relationship ("due to diabetes") and to ensure the osteomyelitis details (site, acute vs chronic) are documented so both codes can be assigned accurately and compliantly.

NEW QUESTION # 25
Which of the following is designed to reduce claims denials and appeals by providing one-on-one feedback to the provider to increase accuracy in specific areas?

A. Recovery Audit Contractor
B. OIG Work Plan
C. Target Probe and Educate
D. Comprehensive Error Rate Testing

Answer: C

Explanation:
Targeted Probe and Educate (TPE) is an education-focused review initiative intended to improve billing accuracy and reduce future denials by combining targeted claim review with direct provider/supplier feedback. In outpatient CDI terms, TPE aligns with a "fix-forward" approach: auditors identify specific error patterns (often documentation, medical necessity, coding, or coverage rule issues), then provide one-on-one education so the provider can correct processes and documentation habits. This is distinct from Recovery Audit Contractors (RACs), which primarily identify and recoup improper payments, often after the fact, and are not structured as an individualized education cycle. The OIG Work Plan identifies oversight priorities and areas of potential fraud/waste/abuse; it does not deliver provider-level coaching to reduce denials. CERT measures Medicare improper payment rates through sampling and can drive policy/education broadly, but it is not designed as individualized, iterative provider education. Because TPE is specifically built around targeted review plus direct education to prevent repeat errors and reduce appeals, it is the best answer.

NEW QUESTION # 26
......

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