The CCDS-O Exam Study Guide

The first years of a clinical documentation integrity (CDI) specialist’s career often feel like a whirlwind of learning—even more so for those embarking on CDI reviews in the outpatient setting. As outpatient CDI efforts continue to grow, CDI professionals increasingly look to show their expertise in what was previously considered a “Wild West” of medical record review priorities.

The Association of Clinical Documentation Integrity Specialists (ACDIS) developed the Certified Clinical Documentation Specialist-Outpatient (CCDS-O) credential to provide a trusted baseline of competency for CDI in the outpatient setting, which includes locations such as physician practices, hospital clinics, and the emergency department.

For those planning to sit for the CCDS-O exam, The CCDS-O Exam Study Guide is their resource to help prepare.

The guide aligns the testing content domains chronologically, matching how CDI professionals obtain core skill sets. It provides targeted information regarding test objectives prepared by the CCDS-O Certification Committee, letting candidates focus their time on areas of CDI practice with which they are least familiar.

This guide includes information related to outpatient coding such as Official Guidelines for Coding and Reporting and Coding Clinic® for ICD-10-CM/PCS recommendations, as well as information about evaluation and management coding, ambulatory payment classifications, and risk adjustment factors. It includes vital information for outpatient CDI professionals related to new query practice guidance from the ACDIS/AHIMA practice brief “Guidelines for Achieving a Compliant Query Practice,” and information on emerging CDI activities related to clinical validation and record reviews for quality-of-care concerns.

Spiral bound to make studying with colleagues easier, it also comes with an online practice exam complete with remediation, so candidates can quickly understand why an answer is correct or incorrect.

The CCDS-O Exam Study Guide will:

• Help candidates determine whether they are ready to take the exam
• Give qualified candidates the confidence they need to succeed
• Provide sample questions for self-assessment

The CCDS-O Exam Study Guide reviews:

• Healthcare regulations, reimbursement, and documentation requirements
• Risk adjustment models
• Quality and regulatory concerns for outpatient initiatives
• Anatomy, physiology, and pharmacology
• The outpatient CDI review process
• Program measures and provider education

Click here to learn more about prerequisites for taking the exam or to apply.

Published: November 2019

Page count: 154
Dimensions: 8.5” X 11” spiral bound
ISBN: 978-1-68308-972-8

Table of Contents

• Healthcare regulations, reimbursement, and documentation requirements
• Risk adjustment models
• Quality and regulatory concerns for outpatient initiatives
• Anatomy, physiology, and pharmacology
• Outpatient CDI review process
• Program measures and provider education

About the Authors

The ACDIS CCDS-O Certification Committee spent more than a year working with the ACDIS administrative staff and PSI/AMP, a third-party exam administration firm, to determine the core competencies and exam questions required for CDI professionals working in the outpatient setting. Once the test was completed, the team turned their attention to creating The CCDS-O Exam Study Guide. Contributors to this volume include:

Tracy Boldt, RN, BSN, CCDS, CDIP

Boldt is the system manager of CDI for Essentia Health System in Duluth, Minnesota. She has more than 15 years of healthcare experience, including nursing, administration, and consulting, specializing in hospital revenue cycle management. Boldt has led CDI engagements for clients representing small hospitals to larger integrated delivery networks with multisite programs. She has successfully led CDI integration projects (inpatient and outpatient), identifying process changes and workflow enhancements regarding how provider documentation is reflective of accurate patient care. Contact her at tracy.boldt@essentiahealth.org. 

Judy Dokken, MBA, CHDA, RHIT, CCS

Dokken is revenue cycle manager for the Mayo Clinic in Rochester, Minnesota. In this role, she works with providers and coding staff to support quality documentation and code capture processes. After many years of facility and professional coding, Dokken transitioned to working with providers on billing requirements, including ICD-10 implementation. After ICD-10, she began work on evaluation and management CPT® documentation and coding. Later, her role expanded to include risk scores, patient complexity, Hierarchical Condition Categories, and Alternative Payment Models. She currently supports the work of Mayo’s outpatient CDI program. Contact her at dokken.judith@mayo.edu. 

Tamara A. Hicks, RN, BSN, MHA, CCS, CCDS, ACM-RN

Hicks is the director of clinical documentation excellence (CDE) at Wake Forest Baptist Health (WFBH) in Winston-Salem, North Carolina, where she is responsible for the enterprise CDE department at WFBH’s five campuses. She was one of the original staff when WFBH rolled out its CDI program in 1999, and since then she has participated in expanding the program by adding all payers, severity of illness, risk of mortality, hospital-acquired conditions, and Patient Safety Indicator reviews to the team’s workflow. Most recently, she has led the team through a restructuring of the CDE department as well as the creation of a new outpatient CDE team. She is a member of the American Case Management Association, AHIMA, and ACDIS, where she served as a founding member of the ACDIS Advisory Board and the CCDS Certification Board. She was re-elected to serve on the ACDIS Advisory Board in 2016. In 2019, she earned the ACDIS CDI Professional of the Year award. Hicks is also an AHIMA-certified ICD-10-CM trainer and a Six Sigma Green Belt. Contact her at thicks@wakehealth.edu. 

Fran Jurcak, MSN, RN, CCDS

Jurcak is the vice president of clinical innovation at Iodine Software. With more than 30 years’ experience in the nursing profession, 10 of them in CDI, she has leveraged her clinical knowledge and experience to provide education, support process improvement, and report outcomes for CDI programs across the country. She received the 2017 ACDIS Recognition of CDI Professional Achievement award and currently serves on the ACDIS CCDS Certification Committee, the ACDIS Advisory Board, and the University of Michigan School of Nursing Alumni Board of Governors. Jurcak is the author of The CCDS Exam Study Guide and is recognized as a national speaker, having presented at many chapter conferences and HCPro webinars. Contact her at fran@iodinesoftware.com.

James Manz, MD

Manz, a consultant in spine and neurological surgery with the Mayo Clinic health system, serves as a physician chair of the Mayo Enterprise Outpatient CDI Subcommittee, physician vice chair for the Mayo Enterprise Inpatient CDI Subcommittee, and physician advisor of the Mayo Clinic Problem List Stewardship Committee. Contact him at manz.james@mayo.edu. 

Shannon E. McCall, RHIA, CCS, CCS-P, CPC, CPC-I, CEMC, CRC, CCDS

McCall is the director of HIM/coding for HCPro in Middleton, Massachusetts, where she directs all of HCPro’s Certified Coder Boot Camp® programs, having most recently collaborated with the CDI team to develop the Risk Adjustment Documentation and Coding Boot Camp®. As a consultant for HCPro, she works with hospitals, medical practices, and other healthcare providers on a wide range of coding-related issues, with a particular focus on education, coding reviews, and audits. McCall has extensive experience with coding for both physician and hospital services. Prior to joining HCPro, she worked for a national medical practice management company, where her duties included serving as a client manager and an in-house coding trainer. She also previously worked for a national consulting firm focusing on hospital inpatient, outpatient, and ER services. McCall previously served on the ACDIS Advisory Board. Contact her at smccall@hcpro.com. 

Karen Newhouser, RN, BSN, CCM, CCDS, CCS, CDIP

Newhouser is director of CDI education for MedPartners in Tampa, Florida, where she has found her niche in education through writing, speaking, and personal engagement. Within multiple roles spanning a 40-year career in critical care nursing, case management, and CDI, she has been resolute in her mission to set people up for success. Newhouser was honored as the 2015 CDI Professional of the Year by ACDIS and was a member of the ACDIS Advisory Board. Contact her at karenmpu@medpartnershim.com. 

Diana Ortiz, JD, RN, CDIP, CCDS

Ortiz is a CDI product owner for 3M Health Information Systems, Inc. Previously, she was the director for ambulatory CDI at Ochsner Health System in New Orleans. After joining Ochsner in 2013, her roles included serving as a project manager as well as an inpatient CDI operations manager. During this time, she coordinated the implementation of computer-assisted coding and metrics reporting for the CDI department. Ortiz has a nursing background in both the emergency and the psychiatric setting, and HIM experience in hospital emergency facility coding and database management. Contact her at dortiz3@mmm.com.

Laurie Prescott, MSN, RN, CCDS, CDIP, CRC

Prescott is the CDI education director for HCPro and ACDIS in Middleton, Massachusetts, where she serves as a full-time instructor for the CDI Boot Camps as well as a subject matter expert. Prescott is a frequent speaker on HCPro/ACDIS webinars and is the author of The CDI Specialist’s Complete Training Guide. Prescott started her nursing career in 1985 and has worked at a variety of organizations, including academic, large, and small community hospitals, in a variety of nursing roles. Her experience also includes specialization as a compliance officer. She currently serves on the ACDIS Advisory Board as well as several ACDIS and HCPro boards and committees. Contact her at lprescott@hcpro.com.

Jessica M. Vaughn, RN, BSN, CCDS

Vaughn is the manager of outpatient clinical documentation excellence (CDE) at Wake Forest Baptist Health (WFBH) in Winston-Salem, North Carolina, where she has worked for nearly 21 years. Coming from a background of bedside nursing service in hematology and oncology acute care and in labor and delivery/GYN surgery, she is currently responsible for leading the outpatient CDE team for WFBH’s network physicians, consisting of 127 ambulatory locations and 317 providers. Over the past three years, Vaughn has helped create and structure processes for the newly formed outpatient CDE team. She has experience in inpatient CDI as well as serving as a clinical documentation compliance coordinator, where she was instrumental in creating a collaborative approach with both quality and coding departments to institutionalize a workflow for accurate reporting of hospital-acquired conditions and Patient Safety Indicators. Vaughn received the 2016 ACDIS Recognition of CDI Professional Achievement award. She is a member of the Sigma Theta Tau International Honor Society of Nursing and obtained her master’s degree in nursing - executive leadership in the summer of 2018. She is an active member of both North Carolina and national ACDIS. Contact her at jessvaug@wakehealth.edu.

Yvonne Whitley, RN, BSN, CPC, CRC, CDEO

Whitley is the manager for the Novant Health ambulatory CDI team, tasked with creating the department in 2013 and building one of the country’s first ambulatory CDI programs. The current program supports much of Novant Health’s more than 530 physician locations and 2,500 providers. Whitley has been with Novant Health for 20 years and comes from a nursing background with 30 years of experience in critical care, trauma, and open-heart ICUs. She also has experience as a clinical research coordinator for drug and device trials. Contact her at yrwhitley@novanthealth.org.

Chapter Previews

Check out these chapter previews for a full idea of what you can expect!

Add Association of Clinical Documentation Integrity Specialists (ACDIS)

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ACDIS is a community of CDI professionals who share the latest tips, tools, and strategies to implement successful CDI programs and achieve professional growth.

ACDIS members receive: 

• Advocacy and leadership from a peer-elected ACDIS Advisory Board, including peer-reviewed Position Papers and White Papers.
• Weekly tips, news, and strategies in our e-newsletter, CDI Strategies
• In-depth news and regulatory information, clinically-based articles, case studies on building successful CDI programs, and membership profiles in our bi-monthly electronic journal, the CDI Journal
• An opportunity to network with peers and colleagues in the ACDIS Forum
• Access to live and archived quarterly conference calls, hour-long networking discussions and an open Q&A with the ACDIS Advisory Board
• Helpful tools accessed in our electronic Resource Library, including sample queries, policies, and archived conference presentations
• Two free job postings a year, discounted additional posts, and the ability to post your resume on our Career Center
• Opportunities to participate in an Official ACDIS Local Chapter in your area, under the leadership of the Chapter Advisory Board
• Discounts to the annual ACDIS conference, CCDS certification, and CDI Boot Camps

To explore all that ACDIS has to offer, please visit the ACDIS Web site.