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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

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 3

Risk Adjustment Models and Impact of Documentation and Coding: Covers CMS-HCC model fundamentals, RAF scoring, Medicare Advantage payments, hierarchies, disease interactions, and compliant HCC reporting requirements.

Topic 4

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.

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ACDIS Certified Clinical Documentation Specialist-Outpatient Sample Questions (Q100-Q105):

NEW QUESTION # 100
What diagnoses are included in code category N18, chronic kidney disease?

A. GFR, ATN, and unspecified kidney failure
B. AKI, ESRD, and dialysis
C. Dialysis, chronic uremia, and polycystic kidney disease
D. CKD stage 3, CKD severe, and ESRD

Answer: D

Explanation:
ICD-10-CM category N18 (Chronic kidney disease) is used to report CKD by stage, including stage-based descriptors and end stage renal disease (ESRD). Within N18, codes identify CKD stage 1 through stage 5, ESRD (stage 5D), and CKD unspecified. Outpatient CDI review focuses on ensuring providers document the stage (often supported by eGFR trends) because stage drives correct code selection and accurately reflects disease severity for risk, quality, and medical necessity. Options that include dialysis are not part of N18 itself; dialysis status and encounter codes are reported elsewhere (e.g., dialysis dependence/status codes), not as N18 category diagnoses. AKI (acute kidney injury) and ATN (acute tubular necrosis) are acute renal conditions and are coded outside N18. Likewise, polycystic kidney disease and "uremia" are separate diagnoses with their own code categories. Therefore, the set that correctly matches what N18 represents is CKD stage-based diagnoses such as CKD stage 3, more advanced/severe CKD stages, and ESRD.

NEW QUESTION # 101
Which of the following is a key component that is used to calculate Relative Value Units (RVUs)?

A. Malpractice expense
B. Medical decision making
C. Physician specialty type
D. Time with the patient

Answer: A

Explanation:
RVUs are the foundation of Medicare's physician fee schedule methodology and are built from three core components: physician work (wRVU), practice expense (peRVU), and malpractice (mpRVU). The malpractice expense RVU reflects the relative professional liability insurance cost associated with providing a service and is a defined element of the RVU calculation used to determine payment rates. In outpatient documentation and CDI education, it's important to distinguish what drives code selection versus what is a payment calculation ingredient. Time with the patient and medical decision making influence E/M code selection under current E/M rules, but they are not standalone components of the RVU formula itself-they contribute indirectly by determining which CPT code is billed, and each CPT code has preassigned RVUs. Physician specialty type also is not a direct RVU component, even though specialty patterns can affect typical service mix and overall wRVU productivity. Therefore, among the options, malpractice expense is the explicit RVU component used in the calculation.

NEW QUESTION # 102
A patient is seen in the office for a persistent cough. Provider documentation states: "History of chronic obstructive pulmonary disease, asthma, and hypertension. Hypertension treated with Enalapril. Cough an adverse effect of the ACE inhibitor; discontinue Enalapril. COPD stable. Instructed to continue meds for COPD/asthma." Which of the following diagnoses should be reported for this encounter?

A. Cough; adverse effect of an ACE inhibitor; COPD, unspecified; hypertension
B. Cough; adverse effect of an ACE inhibitor; COPD, unspecified; asthma, unspecified, uncomplicated; hypertension
C. COPD, unspecified; asthma, unspecified, uncomplicated; hypertension
D. COPD, unspecified; hypertension

Answer: B

Explanation:
Outpatient diagnosis reporting requires coding conditions that are evaluated, assessed, treated, or that influence care/management at the encounter. The chief reason for the visit is the persistent cough, which is assessed and attributed to an adverse effect of an ACE inhibitor (enalapril). For outpatient coding of medication adverse effects, the documentation supports reporting both the manifestation (cough) and the adverse effect of the drug (ACE inhibitor adverse effect), because the provider identified the causal relationship and changed therapy by discontinuing enalapril. In addition, the provider addresses chronic conditions that are clinically relevant to the visit: COPD is assessed as "stable" and the patient is instructed to continue COPD/asthma medications, demonstrating ongoing management. Hypertension also remains relevant because medication therapy is adjusted due to the adverse effect; the patient still has HTN even though one agent is discontinued. Therefore, all five items-cough, ACE inhibitor adverse effect, COPD, asthma, and hypertension-are supported and should be reported, making option D the most appropriate.

NEW QUESTION # 103
CMS-HCCs are used to

A. distribute reimbursement to providers based on quality of care.
B. adjust capitation payments to physicians, excluding advanced practice providers.
C. reimburse physicians based on the principal diagnosis.
D. determine capitation payments to insurers that administer Medicare Advantage health plans.

Answer: D

Explanation:
The CMS-HCC model is a risk adjustment methodology used primarily to set capitated payments for Medicare Advantage (MA) organizations based on the expected cost of caring for their enrolled beneficiaries. Under this approach, CMS calculates a Risk Adjustment Factor (RAF) for each member using demographic variables (such as age/sex and certain entitlement factors) plus disease burden captured from ICD-10-CM diagnoses that map to Hierarchical Condition Categories (HCCs). The resulting RAF increases or decreases the plan's payment to better match predicted healthcare needs-higher RAF for sicker, more complex patients and lower RAF for healthier patients. ACDIS outpatient CDI education emphasizes that the purpose is not physician reimbursement based on a "principal diagnosis" (an inpatient concept) and not payment distribution tied directly to quality performance (that aligns more with MIPS/VBP frameworks). It also does not adjust capitation payments specifically "to physicians," nor does it exclude advanced practice providers in the way described. The correct use is to determine MA plan capitation payments through risk-adjusted member-level projections.

NEW QUESTION # 104
A 75-year-old with a PMH of chronic foot ulcer, CKD, and depression is seen by his PCP for continued fatigue and decreased urination. Labs drawn on previous day are reviewed. Patient describes extreme fatigue and no motivation. Assessment and plan include: "CKD 3 with renal failure - refer to nephrologist. Chronic nonpressure foot ulcer - home care for wound assessment. Depression - Rx for SSRI." Which of the following are the validated diagnoses that risk adjust and qualify as CMS-HCCs?

A. CKD 3; chronic non-pressure ulcer
B. Renal failure; CKD 3
C. Depression; renal failure
D. Chronic non-pressure ulcer; depression

Answer: A

Explanation:
Under CMS-HCC methodology, risk adjustment is driven by ICD-10-CM diagnoses that map to HCC categories and are supported as active conditions addressed at the encounter. CKD stage 3 is a classic HCC-qualifying chronic condition because it represents ongoing kidney disease severity and expected resource use, and in this note it is actively assessed with labs reviewed and a nephrology referral. A chronic non-pressure foot ulcer is also typically HCC-qualifying when documented as ongoing and requiring management, which is supported here by home care/wound assessment planning. In contrast, "depression" (without specification such as major depressive disorder severity/status) commonly does not qualify for HCC in the way major depressive/bipolar categories do, making it less reliable as a risk-adjusting diagnosis. Likewise, "renal failure" is nonspecific and potentially conflicting with CKD stage 3; CDI best practice would be to clarify acuity/severity (acute kidney injury vs CKD stage vs ESRD) rather than assume "renal failure" as an HCC driver. Therefore, the validated HCC-qualifying pair is CKD 3 and chronic non-pressure ulcer.

NEW QUESTION # 105
......

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Dan Shaw Dan Shaw

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