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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 # 21

A record review conducted prior to a primary care appointment indicates a patient has been followed for history of colon cancer. The patient is 18 months s/p bowel resection and is under treatment for LLE DVT, which required monitoring of INR - on Coumadin. The problem list also includes obesity, obstructive sleep apnea (OSA), COPD, and hypertension. Which of the following is the query opportunity?

Options:

A.  

Status of ostomy

B.  

Status of the sleep apnea

C.  

Status of the COPD

D.  

Status of colon cancer

Discussion 0
Question # 22

Clinic documentation states: “Follow-up for post-induction chemotherapy for metastatic uterine cancer.” To BEST identify the conditions being monitored and treated, a CDI specialist should

Options:

A.  

clarify the morphology of the tumor.

B.  

evaluate diagnostic lab results.

C.  

review the record for MRI results.

D.  

query for secondary sites.

Discussion 0
Question # 23

Which of the following is true of the RAF metric?

Options:

A.  

It predicts how much the individual provider will be reimbursed for the concurrent practice year.

B.  

It is based only on demographic factors such as Medicaid status, gender, or aged/disabled.

C.  

It is a relative measure of the probable costs to meet the healthcare needs of the individual beneficiary.

D.  

It is used to calculate each primary care office visit reimbursement based on documentation of chronic conditions.

Discussion 0
Question # 24

During a PCP visit, a provider notes a patient’s history of pathological fracture of the thoracic spine related to osteoporosis. Documentation states: “Decreased muscle mass and significant weight loss in the last six months.” Which of the following should the CDI specialist query for?

Options:

A.  

Degree of muscle atrophy

B.  

Acuity of the pathological fracture

C.  

Type of osteoporosis

D.  

Presence of malnutrition

Discussion 0
Question # 25

Which of the following is a strategy that is often used by ACOs to improve their performance in the Readmission Reduction program?

Options:

A.  

Encourage providers to avoid reporting chronic conditions on subsequent admissions.

B.  

Educate providers about the importance of capturing chronic conditions in documentation.

C.  

Work with IT to increase the unspecified code choices in pick lists in the EHR.

D.  

Flag qualifying patients upon arrival to ED to be placed in observation status vs. admission.

Discussion 0
Question # 26

A morbidly obese patient with a BMI of 45 who is reliant on CPAP at night is likely to have which of the following conditions?

Options:

A.  

Heart failure

B.  

Essential hypertension

C.  

Alveolar hypoventilation

D.  

Pulmonary edema

Discussion 0
Question # 27

Progress note states: “Recent EGD identified severe hyperplasia, without obstruction. Follow-up today for Barrett’s. Complains of chest pain, difficulty swallowing, 15-pound weight loss in last 12 weeks. Diagnoses—significant weight loss, cachexia, anorexia, Barrett’s esophagus, and chest pain. Plan short term tube feeding—consult home health and dietitian for management.” Which of the following diagnoses will trigger an HCC assignment?

Options:

A.  

Barrett’s esophagus

B.  

Anorexia

C.  

Significant weight loss

D.  

Cachexia

Discussion 0
Question # 28

Which of the following lab values, when trended for greater than 3 months, indicates an objective measure of chronic kidney damage?

Options:

A.  

BNP >1000 pg/mL

B.  

GFR <60 ml/min

C.  

BUN <12 mg/dL

D.  

Glucose >100 mg/dL

Discussion 0
Question # 29

A CDI specialist manager is reviewing the productivity metrics of the outpatient team and notes that one of the CDI specialists has a high query rate and a good physician response, but a low physician agree rate compared to the rest of the team. This likely indicates which of the following?

Options:

A.  

The data is not stratified enough to show a true picture of the productivity.

B.  

The CDI specialist is writing leading queries.

C.  

The CDI specialist is creating poor quality queries.

D.  

The cases the CDI specialist is reviewing are more complex than other clinics.

Discussion 0
Question # 30

Which of the following is a provider benefit of a prospective query?

Options:

A.  

Instructs the provider to the best diagnosis to use

B.  

Guarantees risk adjusted diagnosis capture

C.  

Addresses the query topic during the actual patient encounter

D.  

Defines the purpose of the encounter

Discussion 0

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