有効的なCCDS-O学習範囲一回合格-高品質なCCDS-O認定内容あらゆる種類の問題に取り組まれる可能性があります。時には、何かを下に置いて他の問題に対処する必要があります。後者はより緊急であり、すぐに実行する必要があります。 CCDS-Oトレーニングガイドの助けを借りて、あなたの夢がもう遅れることはありません。なぜなら、私たちはクライアントがよりゆっくりと勉強するのを支援するインテリジェントなアプリケーションと高効率のメリットを持っているからです。 CCDS-Oの実際の試験で20〜30時間準備する場合、CCDS-O試験はあなたの前で簡単になります。 ACDIS Certified Clinical Documentation Specialist-Outpatient 認定 CCDS-O 試験問題 (Q60-Q65):質問 # 60
ICD-10-CM code assignment can be supported by documentation from someone other than the patient's provider in which of the following circumstances?
A. Stage of pressure ulcer
B. Type of obesity
C. Site of ostomy
D. Anatomic site of previous amputation
正解：A
解説：
Outpatient ICD-10-CM guidance allows certain code elements to be based on documentation from clinicians other than the patient's diagnosing provider when those elements are considered objective, routinely assessed, and commonly documented by nursing or ancillary staff. A key example is pressure ulcer staging, which is frequently assessed and documented by wound care nurses and other qualified clinicians as part of routine skin/wound evaluation. Because the stage drives code specificity and is an observable clinical finding, coders may use non-provider documentation to assign the stage when it is clearly documented and not contradicted by the provider record. In contrast, items such as the type of obesity generally require provider diagnosis/clinical assessment rather than ancillary documentation alone. Similarly, while status conditions (like amputations or ostomies) may be observed, the coding guidelines do not broadly permit assigning these diagnoses solely from non-provider documentation without provider confirmation, unless the chart otherwise supports it. Therefore, among the choices, pressure ulcer stage is the appropriate circumstance where non-provider documentation can support ICD-10-CM assignment.
質問 # 61
A CDI specialist identifies an opportunity to clarify a patient's BMI. The CDI specialist leaves a query within the medical record for the ancillary support team to address during the patient's visit. Which of the following BEST describes this type of query?
A. Concurrent
B. Prospective
C. Retrospective
D. Prebill
正解：B
解説：
This scenario describes a query placed before the patient is seen, with the intent that the issue be addressed during the upcoming visit. In outpatient CDI practice, that is the defining feature of a prospective query: it is initiated ahead of the encounter so the provider and/or clinic team can capture needed specificity in real time (here, clarifying BMI-related documentation to support an obesity diagnosis when clinically appropriate). By contrast, a concurrent query is typically issued while the encounter is actively occurring or immediately as documentation is being created and reviewed in near-real time. A retrospective query occurs after the visit is completed, usually during post-encounter review, when opportunities are identified after documentation is finalized. "Prebill" refers to a workflow timing concept tied to billing hold/review before claim submission, not the clinical timing of when the patient will be seen. Because the query is placed in advance specifically to be addressed during the scheduled visit, prospective is the best classification.
質問 # 62
Which of the following conditions or findings supports a diagnosis of diabetes?
A. Fasting glucose of 100
B. 2-hour blood sugar level of 90 during oral glucose tolerance test
C. Hypoglycemia
D. Hemoglobin A1c (HbA1c) level of 7.0%
正解：D
解説：
In outpatient clinical documentation and chart review, diabetes can be supported by recognized diagnostic thresholds. An HbA1c value reflects average blood glucose over approximately the prior 2-3 months and is commonly used to diagnose and monitor diabetes. An HbA1c ≥ 6.5% (when confirmed per clinical practice standards and interpreted in the appropriate clinical context) supports a diagnosis of diabetes; therefore an HbA1c of 7.0% clearly meets the threshold and supports diabetes. By comparison, a 2-hour OGTT value of 90 mg/dL is normal and does not support diabetes (diabetes is typically supported when the 2-hour value is ≥ 200 mg/dL). Hypoglycemia is low blood glucose and is not diagnostic of diabetes; it may occur in diabetics due to treatment but can also occur in non-diabetics for many reasons. A fasting glucose of 100 mg/dL is at most borderline/prediabetes range and does not meet diagnostic criteria for diabetes (diabetes is supported at ≥ 126 mg/dL).
質問 # 63
Which of the following BEST describes a Stage 3 pressure ulcer?
A. Pre-ulcer skin changes limited to persistent focal edema
B. Full thickness skin loss involving damage or necrosis of subcutaneous tissue
C. Necrosis of soft tissues through to underlying muscle, tendon, or bone
D. Abrasion, blister, partial thickness skin loss involving epidermis and/or dermis
正解：B
解説：
Stage 3 pressure ulcers are defined by full-thickness skin loss where the injury extends through the dermis and involves damage or necrosis of subcutaneous tissue. Clinically, the ulcer may present as a deep crater and can include undermining or tunneling, but the key boundary is that bone, tendon, and muscle are not exposed. That deeper involvement (exposed muscle/tendon/bone) is characteristic of Stage 4, making option C incorrect. Option D describes partial-thickness loss, which aligns with Stage 2 (epidermis/dermis involvement such as abrasion or blister). Option A reflects early skin changes that correspond more closely to Stage 1 (intact skin with non-blanchable erythema and possible localized edema/induration). In outpatient CDI chart review, accurately distinguishing Stage 3 from Stage 2 and Stage 4 is essential because staging drives severity capture, care planning (wound care interventions, debridement considerations), and quality reporting. Documentation should clearly support "full thickness," the tissue layers involved, and the absence of exposed bone/tendon/muscle.
質問 # 64
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?
A. Cachexia
B. Anorexia
C. Barrett's esophagus
D. Significant weight loss
正解：A
解説：
Within the CMS-HCC model, only certain diagnoses map to HCC categories that contribute to the RAF score. Among the listed options, cachexia is the diagnosis most likely to map to an HCC because it represents a serious systemic wasting condition associated with significant morbidity, higher expected resource use, and frequently coexists with advanced chronic disease. In contrast, Barrett's esophagus generally does not map to an HCC in CMS risk adjustment, and symptom-based diagnoses such as significant weight loss typically do not trigger HCC capture. Anorexia in general clinical usage often represents a symptom (loss of appetite) and, unless it is clearly documented as a qualifying malnutrition-related condition with appropriate specificity, it usually does not map to an HCC. The plan for tube feeding and dietitian involvement strengthens clinical relevance, but for risk adjustment the diagnosis must be one that maps to an HCC category-here, cachexia is the one that meets that criterion and would be the HCC-triggering diagnosis.