ACDIS Certified Clinical Documentation Specialist – Outpatient (CCDS-O)

Which of the following best describes the primary scope of outpatient clinical documentation integrity (CDI)?

• ADocumentation supporting accurate diagnosis capture and risk adjustment across ambulatory…
• BAssignment of MS-DRGs for inpatient admissions
• CCalculation of the inpatient case mix index
• DDetermining the principal diagnosis after discharge

A patient is placed in observation status in the hospital. For coding and billing purposes, observation services are generally considered:

• AInpatient services
• BOutpatient services
• CSkilled nursing services
• DHome health services

Which setting is NOT typically within the scope of an outpatient CDI program?

• AHospital-based physician clinic
• BEmergency department
• CInpatient acute care medical-surgical unit
• DAmbulatory surgery center

An infusion center documents administration of chemotherapy. Outpatient CDI review in this setting most often focuses on ensuring documentation supports:

• AThe inpatient principal procedure
• BDRG relative weight optimization
• CThe 72-hour payment window
• DMedical necessity and the specific drug, dose, and diagnosis driving treatment

In a physician practice, which clinician documentation is typically the basis for diagnosis code assignment in the outpatient setting?

• AThe treating provider's progress note and assessment/plan
• BThe nursing intake vitals only
• CThe lab requisition form alone
• DThe patient's self-reported medical history form

Which professional is the typical end-user audience for outpatient CDI provider education on diagnosis specificity?

• AHospital boiler-room engineers
• BAmbulatory physicians and advanced practice providers
• CInpatient pharmacy technicians only
• DMedical records scanning staff

A key difference between inpatient and outpatient CDI is that outpatient CDI more heavily emphasizes:

• ASequencing the principal diagnosis
• BOptimizing the geometric mean length of stay
• CCapturing chronic conditions affecting risk adjustment over the year
• DQuerying for present-on-admission indicators

An ED encounter results in the patient being discharged home. ED professional services are reported using:

• AMS-DRGs
• BInpatient consultation codes
• CObservation hour-based codes only
• DED E/M codes (99281–99285) based on medical decision making

Why is the ambulatory surgery center (ASC) an important focus for outpatient CDI?

• ADocumentation must support medical necessity and accurate procedure/diagnosis linkage for…
• BASCs assign MS-DRGs
• CASCs require POA reporting
• DASCs use the inpatient-only procedure list for all cases

A CDI specialist notices a provider consistently documents 'diabetes' without specifying type or complications. The CDI role here is primarily to:

• AIndependently assign the most specific code without provider input
• BEducate and query for greater specificity to support accurate code assignment
• CDelete the diagnosis from the record
• DBill the highest-paying diabetes code by default

Which metric is most relevant to an outpatient CDI program focused on risk adjustment?

• ACase mix index
• BGeometric mean length of stay
• CAverage RAF score and HCC recapture rate
• DInpatient mortality index

In the outpatient setting, the term 'encounter' generally refers to:

• AAn entire hospital admission from admit to discharge
• BA calendar quarter of services
• CA bundled 90-day surgical episode
• DA single visit or face-to-face (or telehealth) contact between a patient and provider

According to ICD-10-CM Section IV outpatient guidelines, a diagnosis documented as 'probable,' 'suspected,' or 'rule out' should be:

• ANot coded; instead code the signs, symptoms, or reason for the encounter to the highest c…
• BCoded as if it were an established diagnosis
• CCoded with an uncertainty modifier
• DQueried then coded as confirmed automatically

The ability to code 'probable' or 'suspected' diagnoses as if confirmed applies to which setting?

• APhysician office visits
• BInpatient (short-term, acute, long-term care, and psychiatric hospitals)
• CEmergency department outpatient visits
• DAmbulatory surgery centers

In outpatient coding, the diagnosis chiefly responsible for the services provided during the encounter is called the:

• APrincipal diagnosis
• BAdmitting diagnosis
• CFirst-listed diagnosis
• DComorbid diagnosis

A patient presents for chest pain; after evaluation no definitive cause is found and the provider documents only 'chest pain.' The first-listed diagnosis should be:

• AA presumed cardiac diagnosis
• BA 'rule out myocardial infarction' code
• CAn unspecified heart disease code
• DThe symptom code for chest pain

ICD-10-CM codes can be reported at which levels of specificity for an established diagnosis?

• AOnly at the highest level of specificity available (full character detail)
• BAt any number of characters chosen by the coder
• CAlways exactly three characters
• DAlways exactly five characters

For a patient presenting solely for a diagnostic test (e.g., screening mammogram) with no signs or symptoms, the first-listed code is:

• AThe disease the test is screening for
• BA Z code indicating the screening encounter
• CA symptom code
• DAn unspecified abnormal finding code

Chronic conditions that are managed during an outpatient encounter and affect treatment should be:

• ANever coded in the outpatient setting
• BCoded only once per lifetime
• CCoded as additional diagnoses when documented and clinically relevant to the visit
• DCoded only if they are the chief complaint

The ICD-10-CM convention 'code first' instructs the coder to:

• AAlways list Z codes first
• BReport only the first code found in the index
• CIgnore the order of codes entirely
• DSequence an underlying etiology or condition before the manifestation code

An 'excludes1' note in ICD-10-CM means:

• AThe two conditions cannot be coded together because they are mutually exclusive
• BThe conditions may be coded together when both are present
• CThe note is advisory only
• DBoth codes must always be reported together

For a patient with diabetes and chronic kidney disease, ICD-10-CM combination coding generally requires:

• ATwo unrelated codes with no presumed link
• BA combination code linking diabetic chronic kidney disease plus a CKD stage code
• COnly the diabetes code
• DOnly the CKD code

In ICD-10-CM, the word 'with' or 'in' in the Alphabetic Index or a code title is interpreted to mean:

• AThe conditions are unrelated
• BOnly when the provider explicitly links them
• CA presumed causal/associated relationship between the two conditions
• DA coding error requiring a query in all cases

A 'history of' (personal history) Z code is appropriate when:

• AThe condition is active and being treated
• BThe provider suspects a future condition
• CThe patient has a family member with the condition
• DThe condition no longer exists and is not receiving treatment but may affect care

For an outpatient surgery encounter, if the postoperative diagnosis differs from the preoperative diagnosis, the coder should report:

• AThe postoperative diagnosis because it is the most definitive
• BThe preoperative diagnosis only
• CBoth with the preoperative listed first
• DA symptom code

Which statement about coding 'borderline' diagnoses in the outpatient setting is correct?

• AA borderline diagnosis is always treated as uncertain and not coded
• BA borderline diagnosis is coded as confirmed unless a specific index entry indicates unce…
• CBorderline diagnoses require a query in every case
• DBorderline diagnoses are coded only on inpatient claims

When a patient receives only diagnostic services (e.g., X-ray) and the interpreting physician confirms a definitive diagnosis, the coder should:

• ACode the ordering reason regardless of findings
• BCode a symptom only
• CCode the confirmed diagnosis based on the interpreting physician's documented interpretat…
• DWait for the next visit to code anything

The status of an outpatient diabetes patient on insulin would be captured using:

• AOnly the diabetes code
• BAn external cause code
• CA symptom code
• DA Z code for long-term (current) use of insulin in addition to the diabetes code

Which of the following is the correct outpatient approach to coding a 'possible pneumonia' documented at an office visit with a productive cough and fever?

• ACode the cough and fever (signs/symptoms), not pneumonia
• BCode pneumonia as confirmed
• CCode 'possible pneumonia' with an uncertainty flag
• DQuery then code pneumonia automatically as confirmed

The 2021 office/outpatient E/M coding revisions allow code level selection based on:

• AHistory and exam bullet counts only
• BEither total time on the date of the encounter or the level of medical decision making (M…
• CNumber of body systems examined only
• DCounting review-of-systems elements only

Under the 2021 MDM table, how many of the three MDM elements must meet or exceed a level to select that overall MDM level?

• AAll three elements
• BOnly one element
• CTwo of the three elements
• DNone; time is always used

The three elements of medical decision making used for 2021 office E/M leveling are:

• AHistory, exam, and MDM
• BChief complaint, ROS, and PFSH
• CTime, place, and acuity
• DNumber/complexity of problems addressed; amount/complexity of data; risk of complications

There are how many levels of MDM in the 2021 office/outpatient E/M framework?

• AFour: straightforward, low, moderate, and high
• BThree: low, moderate, high
• CFive levels
• DTwo: simple and complex

For an established patient office visit selected by MDM at the moderate level, the correct E/M code is:

• A99204
• B99214
• C99212
• D99215

When using total time to select a 2021 office E/M level, which activities count?

• AOnly face-to-face time
• BOnly time spent by clinical staff
• CBoth face-to-face and non-face-to-face time by the physician/QHP on the encounter date
• DTime across multiple days

Which CPT modifier indicates a significant, separately identifiable E/M service performed on the same day as a procedure by the same provider?

• AModifier 59
• BModifier 26
• CModifier 51
• DModifier 25

Modifier 59 is used to identify:

• AA distinct procedural (non-E/M) service not normally reported together
• BA separately identifiable E/M service
• CThe technical component of a service
• DAn unrelated procedure during a postoperative period

CPT codes are maintained by which organization?

• ACMS
• BThe American Medical Association (AMA)
• CThe World Health Organization
• DNCQA

HCPCS Level II codes are primarily used to report:

• AInpatient procedures only
• BHospital DRG groupings
• CProducts, supplies, drugs, and services not described by CPT (e.g., J-codes for drugs)
• DDiagnoses

Under the 2021 E/M guidelines, a 'stable chronic illness' addressed at the visit contributes to which MDM element?

• AAmount and complexity of data
• BRisk of complications
• CTotal time only
• DNumber and complexity of problems addressed

Which of the following items contributes to the 'amount and/or complexity of data' MDM element?

• AIndependent interpretation of a test performed by another provider
• BThe number of chronic illnesses present
• CThe patient's social determinants of health
• DThe drug therapy requiring intensive monitoring

Prescription drug management during an office visit is generally categorized in the 2021 MDM table as which level of risk?

• AMinimal risk
• BModerate risk
• CLow risk
• DHigh risk

Prolonged services code 99417 (or G2212 for Medicare) may be reported with an office E/M visit when:

• AMDM is straightforward
• BThe visit is for a new patient only
• CTime-based code selection is used and total time exceeds the highest-level code's thresho…
• DAny visit exceeds 15 minutes

A documentation gap that prevents accurate E/M leveling by MDM most commonly involves:

• AOmission of the patient's address
• BLack of a signed consent form
• CMissing insurance card copy
• DFailure to document the assessment of each problem and the management/plan

For a NEW patient office visit with straightforward MDM, the correct CPT code is:

• A99202
• B99212
• C99203
• D99204

A patient is seen for a laceration repair and, separately, evaluated for newly worsening hypertension during the same visit. To report both the E/M and the repair, the provider should:

• AAppend modifier 59 to the E/M code
• BAppend modifier 25 to the E/M code
• CReport the E/M without any modifier
• DReport only the procedure