ACDIS Clinical Documentation Specialist CCDS-O

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ACDIS CCDS-O Exam Syllabus Topics:

Reference: https://acdis.org/sites/acdis/files/Handbook_CCDS_CCDS-O.pdf

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ACDIS Certified Clinical Documentation Specialist-Outpatient Sample Questions:

Question #1
Which statement is MOST accurate about the problem list?

A. A CDI specialist should update the problem list to provide continuity of care.
B. Problem list diagnoses should be removed after one year.
C. A well-maintained problem list is vital in the continuity of patient care.
D. More diagnoses on the problem list assist the provider in caring for the patient.

Question #2
A female patient presents for her yearly wellness check-up. Her vital signs are within normal limits with the exception of dyspnea. Her weight is 165 lbs, up 10 lbs from her previous clinic visit 2 weeks prior. Problem list includes diagnoses of obesity, COPD, heart failure, and diabetes without complications. The patient's A1c noted 9.2 up from 7.2 from previous year wellness exam. Based on the clinical indicators, which of the following medications should be evaluated and addressed during this clinic visit?

A. Metformin and methotrexate
B. Wellbutrin and Allegra
C. Megace and ferrous sulfate
D. NovoLog and Lasix

Question #3
Based on previous documentation, which of the following diagnoses would a CDI specialist be MOST likely to bring to the provider's attention in preparation for an upcoming visit of a 70-year-old patient?

A. Chronic obstructive lung disease, T3 compression fracture, and s/p kidney transplant
B. Epilepsy, chronic heart failure, and Crohn's disease
C. Family history of lung cancer, atrial fibrillation, and sickle cell
D. Diabetes mellitus, syncopal episode, and pharyngitis

Question #4
After a CDI specialist describes how RAF is calculated, a provider states, "I just don't see how this impacts patient care." Which of the following is the MOST appropriate response related to the RAF score?

A. "It predicts medical necessity of ordered procedures/treatments."
B. "It predicts expected resources needed to care for the patient."
C. "It determines the patient's out of pocket expenses."
D. "It determines what you will be reimbursed."

Question #5
A patient is seen by an endocrinologist to manage his poorly controlled diabetes with peripheral neuropathy and claudication. The patient has had several toes amputated in prior years and currently has a non-healing ulcer on the left foot. The patient's additional chronic conditions consist of the following: HF, CAD, COPD, history of prostate cancer, arthritis, depression, and sleep apnea. Which of the following chronic conditions should the CDI specialist consider for future education regarding RAF impact with the endocrinologist?

A. History of prostate cancer, arthritis, and A1C
B. Diabetes, amputation, and skin ulcer
C. Sleep apnea, depression, and HF
D. CAD, diabetes, and COPD

Solutions: