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

Certified Clinical Documentation Specialist-Outpatient (CCDS-O)

Last Update Apr 25, 2026
Total Questions : 140

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Questions 2

Upon retrospective review of a patient visit 2 weeks prior, a CDI specialist notes physician documentation stating the following: “Sick Sinus Syndrome in 2016 s/p pacemaker placement. Latest EKG shows normal paced rhythm.” There are no codes noted for Sick Sinus Syndrome or the pacemaker. Which of the following is the BEST course of action for the CDI specialist?

Options:

A.  

Capture code for pacemaker status only.

B.  

Request the provider amend the codes to reflect the Sick Sinus Syndrome and pacemaker status.

C.  

Educate the provider that a pacemaker status code as well as a Sick Sinus Syndrome code should be assigned.

D.  

Ask the coder to re-bill based upon the documentation.

Discussion 0
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Questions 3

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
Questions 4

HCC category assignment methodology is similar to which of the following?

Options:

A.  

DRG diagnostic categories

B.  

835 claim submission

C.  

ICD-10-PCS coding

D.  

CPT coding

Discussion 0
Questions 5

In February, a patient is diagnosed with prostate cancer, which is classified as HCC 23. In October, the patient is diagnosed with prostate cancer with bone metastases, which is classified as HCC 18. Which of the following is true about the patient’s risk score?

Options:

A.  

The risk score will be calculated based upon HCC 23 because it was captured first.

B.  

The risk score will be calculated based upon HCC 18 because it has the highest weight in the hierarchy HCC 23.

C.  

The risk score will be calculated based upon HCC 18 and HCC 23 because they were both documented and coded in the same calendar year.

D.  

The risk score will not be impacted by the presence of HCC 18 or HCC 23 because they are not currently being treated.

Discussion 0

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