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ACDIS CCDS-O Exam Syllabus Topics:

TopicDetails
Topic 1
  • Coding and Reporting, the Outpatient Prospective Payment System (OPPS), and provider coding
Topic 2
  • Healthcare regulations, reimbursement, and documentation requirements related to the Official Guidelines for
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.

ACDIS Certified Clinical Documentation Specialist-Outpatient Sample Questions (Q59-Q64):

NEW QUESTION # 59
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?

Answer: B

Explanation:
This encounter documents both hypertension and heart failure management, creating a key outpatient documentation/coding clarification opportunity: whether the heart failure is related to hypertension (hypertensive heart disease with heart failure). Outpatient CDI principles emphasize capturing the true clinical relationships that affect code assignment, risk adjustment, and longitudinal disease management. When HTN and HF coexist, coding may require combination coding and correct sequencing, plus an additional heart failure code to describe the specific HF type. Provider documentation that explicitly links (or explicitly rules out) a causal relationship supports compliant selection of the most accurate diagnosis codes and reduces ambiguity during chart review. The other options are weaker: the provider already documents HFrEF (type), and while added severity detail can help, the scenario's primary clarification "opportunity" is the HTN-HF relationship. DM type 1 inherently involves insulin, so "insulin status" is not the key outpatient clarification point here, and there is no typical direct linkage between DM and arthritis supported by the note.


NEW QUESTION # 60
In a year over year comparison, the total number of patients with the more specific diagnosis of morbid obesity versus unspecified obesity increased from 10,000 patients to 11,000 patients. Which of the following is the hypothetical increase in yearly reserve for that patient population? (Morbid obesity HCC value = 0.186 and PMPM = $800.00)

Answer: A

Explanation:
This question applies the outpatient risk adjustment "reserve" concept: predicted cost is estimated by multiplying the member's risk factor contribution by a baseline per-member-per-month (PMPM) amount, then annualizing. The morbid obesity HCC factor is 0.186, and PMPM is $800. First compute the monthly cost impact: $800 × 0.186 = $148.80 per month per patient. Convert to yearly: $148.80 × 12 = $1,785.60 per patient per year. The year-over-year increase in patients with morbid obesity documentation is 11,000 - 10,000 = 1,000 additional patients. Multiply the annual per-patient impact by the additional patient count: $1,785.60 × 1,000 = $1,785,600. Outpatient CDI programs emphasize that improving documentation specificity (when clinically supported) can change whether an HCC is captured, which can affect RAF-based projections and resource planning. However, documentation must still be accurate, supported, and reflect conditions assessed/managed during the encounter.


NEW QUESTION # 61
Provider documentation states: "Patient is here for follow-up for multiple chronic conditions, including COPD, HTN, DM, and alcohol abuse. She admits to drinking more than she has in the past, starting in the early morning and consumes at least a pint a day. Her BP today is elevated at 165/89. Discussed medications and diet. As she continues to be dependent on alcohol, several treatment options were offered. She stated she would think about it." Which of the following groups of diagnoses is supported by the clinical indicators described?

Answer: B

Explanation:
The clinical indicators strongly support alcohol dependence, not merely alcohol "use" or "abuse." The patient reports heavy, compulsive intake (early-morning drinking and at least a pint daily), and the provider explicitly documents that she "continues to be dependent on alcohol" and discusses treatment options-this aligns with a dependence-level disorder being addressed. Hypertension is also supported because the BP is elevated (165/89) and the provider documents management activity (medications and diet counseling), meeting encounter relevance/reportability expectations. Diabetes is listed among chronic conditions, but the scenario provides no indicators of complications (no neuropathy, CKD, ulcers, retinopathy, etc.), so the supported choice is DM type 2 without complications rather than "with complications." Although COPD is listed in the "including" statement, no COPD-specific assessment/monitoring/treatment is described in the indicators provided, so the best-supported grouped option focuses on the conditions with clear supporting indicators and management in the note: DM2 without complications, HTN, and alcohol dependence.


NEW QUESTION # 62
When should the assignment of a not elsewhere classified (NEC)/other specified code be reported?

Answer: B

Explanation:
In outpatient CDI and ICD-10-CM coding guidance emphasized in ACDIS education, "NEC" (Not Elsewhere Classified) aligns with the "other specified" options in the code set and is used when the provider's documentation is clinically specific, but the classification system does not offer a unique code for that exact specificity. In other words, the record contains enough detail to describe a distinct type, cause, manifestation, or clinical variation of a condition, yet there is no more precise code available, so the "other specified" category appropriately captures that documented specificity. This is the opposite of "unspecified" (often associated with "NOS"), which is selected when the documentation is not detailed enough to choose a more specific code option. From a chart review perspective, NEC/other specified supports accurate reporting because it reflects that the clinician did document additional detail, and the coder is not defaulting to unspecified due to missing documentation-rather, the code set itself limits further granularity.


NEW QUESTION # 63
What is the goal of an MSSP program?

Answer: B

Explanation:
The Medicare Shared Savings Program (MSSP) is designed to move reimbursement away from pure volume-based payment and toward value by rewarding organizations that reduce the total cost of care for an assigned Medicare population while meeting defined quality performance requirements. In MSSP, eligible provider groups participate as Accountable Care Organizations (ACOs) and are compared against a financial benchmark. If the ACO's actual spending comes in below the benchmark and quality standards are achieved, the ACO can earn a portion of the savings-hence "shared savings." Outpatient CDI supports MSSP success by ensuring documentation accurately reflects patients' true disease burden (supporting appropriate risk adjustment for benchmarking), and that conditions addressed during visits are clearly documented as evaluated/managed to support reliable coding and quality measurement. While improving transitions of care may be a strategy that helps achieve savings and quality goals, it is not the core purpose of the program itself. Likewise, MSSP is not intended to increase fee schedule payments or simply optimize risk scores; the primary aim is participating in value-based care and sharing in savings when performance supports it.


NEW QUESTION # 64
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