ACDIS Certified Clinical Documentation Specialist-Outpatient - CCDS-O Exam Practice Test

Which of the following conditions or findings supports a diagnosis of diabetes?

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

Provider documentation states: "A patient is seen today with DM type 2, peripheral neuropathy with diabetic ulcer of the left great toe, hypertension, and BMI 43. O2 dependent, chronic respiratory failure due to COPD, stopped smoking 2 years ago - 84 packs per year smoking habit." Which of the following query opportunities will impact risk adjustment?

Which of the following is a form of a cardiac condition that may be treated with a beta-blocker?

A patient is evaluated in the clinic. Documentation states: "HIV positive, gravida 1 at 24 weeks." Which of the following conditions will be coded and in which sequence based on the documentation?

While away on vacation, a patient sustained a compound right femoral shaft fracture requiring ORIF. Upon the patient's return home, the fracture site is determined by the orthopedist to be healing well without any complication. Which of the following diagnoses is MOST appropriate for this office follow-up?

Which of the following are appropriate clinical indicators to support a query related to alcohol dependency in remission?

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?

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?

A compliant physician query must: