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

Question 1

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. Sleep apnea, depression, and HF

B. Diabetes, amputation, and skin ulcer

C. History of prostate cancer, arthritis, and A1C

D. CAD, diabetes, and COPD

Correct Answer: B

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Question 2

Which of the following best differentiates inpatient from outpatient coding guidelines?

A. Outpatient guidelines focus on principal diagnoses

B. Outpatient coding ignores encounter diagnoses

C. Both use the same guidelines with no differences

D. Inpatient guidelines emphasize diagnosis sequencing and MS-DRGs

Correct Answer: D

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Question 3

Which of the following diabetic complications requires the assignment of a combination code plus the code for the specific complication?

A. Dermatitis

B. Retinopathy

C. Nephropathy

D. Osteomyelitis

Correct Answer: D

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Question 4

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

A. Conversion factors

B. Hierarchies

C. Disease interactions

D. Resource-based relative values

Correct Answer: C

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Question 5

The principal diagnosis is defined as:

A. Any condition treated during the hospital stay

B. The condition established after study to be chiefly responsible for occasioning the admission

C. The most severe condition present

D. The first diagnosis listed on the chart

Correct Answer: B

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Question 6

A patient presents for a right inguinal herniorrhaphy in ambulatory surgery and is placed in observation status postoperatively. Provider documentation states: "Observation related to the post procedural urinary retention likely related to benign prostatic hyperplasia or adverse reaction to anesthesia." From this documentation, which of the following is the first-listed diagnosis?

A. Benign prostatic hyperplasia

B. Urinary retention

C. Right inguinal hernia

D. Adverse reaction to anesthetic

Correct Answer: B

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Question 7

When a CDI specialist identifies a discrepancy in documentation, the next step is to:

A. Query the provider for clarification

B. Change the record

C. Code the record as is

D. Escalate to compliance

Correct Answer: A

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Question 8

Provider documentation states: "A 72-year-old patient with an active history of colon cancer, status post bowel resection, receiving chemotherapy. Newly diagnosed lung metastasis. Presents with UTI and elevated creatinine. Labs demonstrate a hemoglobin of 7.9, WBC of 2,500, and platelet count of 20,000." Which of the following is the query opportunity that supports a disease interaction that impacts the risk adjustment?

A. Acute tubular necrosis and UTI

B. Colon cancer and chemotherapy

C. Colon cancer and lung metastasis

D. Chemotherapy induced pancytopenia

Correct Answer: D

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Question 9

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

A. CPT codes

B. APCs

C. Physician Fee Schedule

D. DRGs

Correct Answer: B

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