Exam Name: Certified Clinical Documentation Specialist-Outpatient
Certification Provider: ACDIS
Corresponding Certification: Clinical Documentation Specialist
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ACDIS CCDS-O Exam Syllabus Topics:
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Reference: https://acdis.org/sites/acdis/files/Handbook_CCDS_CCDS-O.pdf
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ACDIS Certified Clinical Documentation Specialist-Outpatient Sample Questions:
Which of the following best differentiates inpatient from outpatient coding guidelines?
- A. Both use the same guidelines with no differences
- B. Inpatient guidelines emphasize diagnosis sequencing and MS-DRGs
- C. Outpatient coding ignores encounter diagnoses
- D. Outpatient guidelines focus on principal diagnoses
Correct Answer: B 🗳️
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A patient is seen in the obstetrical clinic, 6 weeks postpartum. She presents with resting heart rate of 58 BPM, initial blood pressure of 154/90, and respiratory rate of 20. She also complains of slight headaches, denies visual changes, and has no evidence of peripheral edema. History is significant for smoking and obesity. A blood pressure reading of 160/88 is taken at the end of the visit. The provider documents hypertension. Which of the following query opportunities is MOST appropriate?
- A. Whether the hypertension was pre-existing or developed during pregnancy
- B. Hypertensive crisis - unspecified
- C. A more specific diagnosis, such as pre-eclampsia or eclampsia
- D. Association of hypertension to smoking
Correct Answer: A 🗳️
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While away on vacation, a patient sustained a compound right femoral shaft fracture requiring ORIF. Upon the patient's return home, the fracture site is determined by the orthopedist to be healing well without any complication. Which of the following diagnoses is MOST appropriate for this office follow-up?
- A. Unspecified fracture of shaft of right femur, subsequent encounter for routine healing, open fracture type I or II
- B. Unspecified fracture of shaft of right femur, initial encounter, closed fracture
- C. Unspecified fracture of shaft of right femur, initial encounter, open fracture type I or II
- D. Unspecified fracture of shaft of right femur, subsequent encounter for routine healing, closed fracture type I or II
Correct Answer: A 🗳️
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Upon retrospective review of a patient visit 2 weeks prior, a CDI specialist notes physician documentation stating the following: "Sick Sinus Syndrome in 2016 s/p pacemaker placement. Latest EKG shows normal paced rhythm." There are no codes noted for Sick Sinus Syndrome or the pacemaker. Which of the following is the BEST course of action for the CDI specialist?
- A. Educate the provider that a pacemaker status code as well as a Sick Sinus Syndrome code should be assigned.
- B. Ask the coder to re-bill based upon the documentation.
- C. Capture code for pacemaker status only.
- D. Request the provider amend the codes to reflect the Sick Sinus Syndrome and pacemaker status.
Correct Answer: C 🗳️
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An ACO with 50,000 beneficiaries just completed its first year of a 3-year contract where the final scores were quality 90%; expected costs were $50 million, and actual costs were $52 million. The shared savings rate determined by CMS was 50%. Which of the following is MOST accurate and applies for the ACO?
- A. The ACO will have shared savings or penalty determined at the end of the agreement period.
- B. The ACO will expect to receive dollars in shared savings.
- C. The ACO will expect to pay back dollars in shared savings.
- D. The ACO will be eligible for shared savings after the second year.
Correct Answer: C 🗳️
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