Detailed CCDS-O Study Plan - CCDS-O Exam Questions Vce

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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
  • Healthcare regulations, reimbursement, and documentation requirements related to the Official Guidelines for
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
  • Coding and Reporting, the Outpatient Prospective Payment System (OPPS), and provider coding

ACDIS Certified Clinical Documentation Specialist-Outpatient Sample Questions (Q34-Q39):

NEW QUESTION # 34
A CDI specialist has created the following query:
"Dear Dr., Based on the following clinical indicators: history of CVA and physical therapy ordered to address left sided weakness, please confirm a diagnosis of hemiplegia." What feedback should be given to the CDI specialist regarding the query?

Answer: D

Explanation:
This query is non-compliant because it is leading: it asks the provider to "confirm a diagnosis of hemiplegia," presenting only one targeted outcome rather than requesting clarification in a neutral, clinically appropriate way. ACDIS-aligned outpatient query practice requires queries to be compliant, non-leading, and supported by clinical indicators, typically offering multiple reasonable options (or an open-ended format) and allowing the provider to document the most accurate clinical impression. In this scenario, "history of CVA," "left-sided weakness," and "physical therapy ordered" could reflect several possibilities-such as hemiparesis, residual weakness, post-stroke deficits, deconditioning, or other neurologic impairment-so the query should ask the provider to clarify the nature and diagnosis of the deficit (and laterality), not to confirm a single diagnosis. Option A is incorrect because coding cannot assume hemiplegia without provider documentation. Option C is not the best feedback because indicators can justify clarification. Option D is unnecessary; MRI results are not required for a compliant outpatient query.


NEW QUESTION # 35
In the outpatient setting, which of the following guidelines depicts the reason for the encounter/visit shown in the medical record to be chiefly responsible for the services provided?

Answer: B

Explanation:
In outpatient and physician-office reporting, the diagnosis that best describes the main reason for the visit is reported as the first-listed diagnosis. Outpatient coding guidance emphasizes that the "principal diagnosis" concept is primarily an inpatient construct (the condition established after study to be chiefly responsible for admission). In ambulatory encounters, patients are often seen for evaluation, management, follow-up, or symptom assessment, so the coding framework uses first-listed to identify the condition, problem, or symptom chiefly responsible for the services provided during that encounter. Co-existing conditions may also be reported when they are addressed or affect care (e.g., monitored, evaluated, assessed/managed, or treated), but they do not replace the requirement to sequence the primary reason for the visit first. Differential diagnoses are not used as the "reason chiefly responsible" in outpatient coding unless a confirmed diagnosis is established; if uncertainty remains, symptoms may be reported instead. Therefore, "first-listed diagnosis" is the correct term for the outpatient setting.


NEW QUESTION # 36
Provider documentation states: "A 72-year-old patient with an active history of colon cancer, status post bowel resection, receiving chemotherapy. Newly diagnosed lung metastasis. Presents with UTI and elevated creatinine. Labs demonstrate a hemoglobin of 7.9, WBC of 2,500, and platelet count of 20,000." Which of the following is the query opportunity that supports a disease interaction that impacts the risk adjustment?

Answer: C

Explanation:
In outpatient risk adjustment, "disease interactions" refer to model coefficients that are triggered when certain clinically related conditions co-exist, reflecting higher expected resource use than either condition alone. In this case, the record already supports active malignancy care (colon cancer on chemotherapy) with newly documented metastasis, and the lab pattern (anemia, leukopenia, and severe thrombocytopenia) strongly suggests pancytopenia. The highest-yield query opportunity is to clarify whether the cytopenias represent chemotherapy-induced pancytopenia (or another specified etiology) because a confirmed, well-specified hematologic complication in the context of active cancer treatment is the type of combination that commonly drives interaction effects in risk models (cancer plus significant systemic complication/manifestation). Options A and B describe clinical context but do not, by themselves, establish an interaction-ready, separately reportable complication. Option C is unrelated to the presented lab-driven severity signal. Querying and documenting chemotherapy-induced pancytopenia supports accurate capture of severity and the interaction impact.


NEW QUESTION # 37
A patient with stage 3 CKD presents to the clinic for evaluation. Upon review of labs, an elevated iPTH and a normal phosphorus level are noted. Which of the following diagnoses may be appropriately queried based upon these lab values?

Answer: B

Explanation:
In stage 3 chronic kidney disease, impaired vitamin D activation and early disturbances in calcium-phosphate regulation commonly drive a compensatory rise in parathyroid hormone (PTH), known as secondary hyperparathyroidism of renal origin. Outpatient CDI chart review looks for clinical indicators that suggest a condition being evaluated or requiring management, and an elevated iPTH in a CKD patient is a classic indicator that supports querying the provider for CKD-related mineral and bone disorder, specifically renal secondary hyperparathyroidism, if it is clinically being assessed/treated (e.g., monitoring trends, prescribing vitamin D analogs, calcimimetics, dietary counseling, nephrology follow-up). Primary hyperparathyroidism is less supported here because it typically requires a different biochemical pattern and clinical context (often hypercalcemia) rather than being driven by CKD physiology. Hypoparathyroidism is the opposite process (low PTH), making option C inconsistent with the lab finding. Option D is not supported because phosphorus is normal, not low, and hypophosphatemia is not documented as a driver. Therefore, querying for renal secondary hyperparathyroidism is most appropriate.


NEW QUESTION # 38
Which of the following diabetic complications requires the assignment of a combination code plus the code for the specific complication?

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 # 39
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