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Free Certified Clinical Documentation Specialist-Outpatient (CCDS-O) Practice Questions

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Exam style questions across every CCDS-O domain

Last Update 22 hours ago
Total Questions : 140

Start with our free CCDS-O practice questions, carefully crafted to mirror the domains, phrasing, and difficulty of the real Clinical Documentation Specialist exam. Each CCDS-O exam question comes with a detailed rationale that explains not just which answer is correct but why the others fall short. That's how concepts stick. Use the free set to benchmark yourself: identify your ACDIS weak domains, see where you're losing marks, and build a focused study plan in minutes.

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Question # 11

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?

Options:

A.  

Megace and ferrous sulfate

B.  

Metformin and methotrexate

C.  

NovoLog and Lasix

D.  

Wellbutrin and Allegra

Discussion 0
Question # 12

The primary purpose of clinical documentation improvement (CDI) is to:

Options:

A.  

Increase hospital reimbursement

B.  

Ensure accurate and complete documentation reflecting patient severity and care provided

C.  

Simplify the physician’s workflow

D.  

Reduce coding workload

Discussion 0
Question # 13

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?

Options:

A.  

DM Type 2 without complications, HTN, alcohol abuse

B.  

DM Type 2 with complications, COPD, HTN, alcohol use

C.  

DM Type 2 without complications, HTN, alcohol dependence

D.  

DM Type 2 with complications, COPD, alcohol dependence

E.  

F.  

G.  

Discussion 0
Question # 14

Which performance metric is MOST appropriate for an outpatient program to share with providers?

Options:

A.  

APC payment rates

B.  

RAF scores

C.  

HCC per member per month payments

D.  

Major complication comorbidity (MCC) rates

Discussion 0
Question # 15

A CDI specialist is following up on a query while the provider is seeing patients in the clinic. The BEST action that will support a quick and compliant response to the query is to

Options:

A.  

wait to speak with the provider during the next scheduled meeting.

B.  

catch the provider in the hallway between patients.

C.  

discuss in a private room with the door closed.

D.  

leave a sticky note on the chart of the next patient.

Discussion 0
Question # 16

Which component of the OPPS assigns payment rates based on procedure grouping?

Options:

A.  

Physician Fee Schedule

B.  

APCs

C.  

DRGs

D.  

CPT codes

Discussion 0
Question # 17

ICD-10-CM code assignment can be supported by documentation from someone other than the patient’s provider in which of the following circumstances?

Options:

A.  

Anatomic site of previous amputation

B.  

Type of obesity

C.  

Stage of pressure ulcer

D.  

Site of ostomy

Discussion 0
Question # 18

A patient is scheduled to see his PCP in 3 days. A CDI specialist notes that during the patient's last visit earlier this year, the problem list shows both DM 2 associated erectile dysfunction and DM 2 without complications. The last clinic note states that DM 2 with autonomic neuropathy was addressed. The CDI specialist should do which of the following FIRST?

Options:

A.  

Remove DM 2 without complications from the problem list

B.  

Query if the DM 2 is with or without complications

C.  

Ask the patient if he still has DM 2 with autonomic neuropathy

D.  

Query the provider for the link between erectile dysfunction and DM 2

Discussion 0
Question # 19

PCP notes describe declining renal function with creatinine trending upward over the last 12 months. Nephrology consult ordered. Which of the following diagnostic tests could support a query to identify status of the patient’s baseline renal function?

Options:

A.  

Creatinine

B.  

BUN (Blood urea nitrogen)

C.  

eGFR (glomerular filtration rate)

D.  

ACR (albumin to creatinine ratio)

Discussion 0
Question # 20

Which of the following adds weight to the risk score over and above the CMS-HCC weights for individual conditions?

Options:

A.  

Hierarchies

B.  

Disease interactions

C.  

Resource-based relative values

D.  

Conversion factors

Discussion 0

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