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ACDIS CCDS-O Exam Syllabus Topics:
| Section | Objectives |
|---|---|
| Quality Initiatives | - Patient Safety - HEDIS Measures |
| Disease Processes and Clinical Concepts | - Anatomy and Physiology
|
| Clinical Documentation Integrity (CDI) Program Operations | - Query Process
|
| Healthcare Regulations and Reimbursement | - Risk Adjustment Models
|
ACDIS CCDS-O Exam: Questions Before You Commit
The ACDIS Certified Clinical Documentation Specialist-Outpatient blueprint is divided into 4 domains, headlined by Clinical Documentation Integrity (CDI) Program Operations, Quality Initiatives, and Disease Processes and Clinical Concepts. The full weighted outline is in the syllabus section above — our materials are revised against it, and your study hours should follow it too.
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Candidates must have a background in healthcare, coding, or clinical documentation.
Vendor rules change periodically, so before booking, confirm the current criteria on the official ACDIS exam page.
The CCDS-O exam — full name Certified Clinical Documentation Specialist-Outpatient — is ACDIS's certification exam for professionals working with its technologies; passing it awards the Clinical Documentation Specialist certification. It is the kind of vendor-issued proof employers can compare across candidates, which is exactly why it stays in demand. It also leads naturally toward CCDS.
ACDIS Certified Clinical Documentation Specialist-Outpatient Sample Questions:
A female patient who underwent total hip replacement 2 weeks ago is in for a follow-up visit with her PCP. The visit note states: "Patient complains of fatigue and lethargy. Hgb on discharge was 10.4gm/dL - now is 8.6 gm/dL. Will start FeSO4 325mg po daily with food. Repeat H/H in 2 weeks. She has return visit with Ortho then." Which of the following is the BEST course of action for the CDI specialist?
- A. Add acute blood loss anemia to the diagnoses reported on the claim.
- B. Instruct the provider to add iron deficiency anemia to the problem list.
- C. Review the lab work referenced by the provider in the progress note for congruence.
- D. Query the provider for a diagnosis related to fatigue, decreased Hgb, and FeSO4.
Correct Answer: D 🗳️
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Provider documentation states: "A patient is seen today with DM type 2, peripheral neuropathy with diabetic ulcer of the left great toe, hypertension, and BMI 43. O2 dependent, chronic respiratory failure due to COPD, stopped smoking 2 years ago - 84 packs per year smoking habit." Which of the following query opportunities will impact risk adjustment?
- A. Diabetes with complications
- B. Nicotine dependence
- C. Morbid obesity
- D. Depth of diabetic ulcer
Correct Answer: D 🗳️
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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?
- A. DM Type 2 without complications, HTN, alcohol abuse
- B. DM Type 2 with complications, COPD, HTN, alcohol use
- C. DM Type 2 with complications, COPD, alcohol dependence
- D. DM Type 2 without complications, HTN, alcohol dependence
Correct Answer: D 🗳️
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If a patient is being seen for follow-up and the documentation indicates that the patient was admitted to the hospital 28 days ago with an acute cerebral infarction with remaining right-sided weakness, which of the following diagnoses would be MOST appropriate?
- A. Cerebral infarction, unspecified, hemiparesis affecting right dominant side
- B. Hemiparesis following cerebral infarction affecting right dominant side
- C. Hemiparesis following cerebral infarction affecting unspecified side
- D. Other sequelae of cerebral infarction
Correct Answer: B 🗳️
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When compliantly querying providers, CDI specialists or HIM/coding professionals may
- A. omit clinical indicators in a query as this may be leading to the provider.
- B. offer diagnoses choices supported by documentation solely from previous encounters.
- C. offer a new diagnosis, that is supported by the clinical evidence, as an option in a multiple-choice query.
- D. identify which diagnoses are HCCs.
Correct Answer: C 🗳️
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