ACDIS Clinical Documentation Specialist CCDS

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ACDIS Certified Clinical Documentation Specialist Sample Questions:

Question #1
A physician responds to a clinically supported CDI query by stating that the proposed diagnosis does not apply and documents a different diagnosis supported by the patient's condition. What is the BEST action by the CDI specialist?

A. Escalate every disagreement to the chief medical officer
B. Accept the physician's clinical judgment and ensure the resulting documentation is clear
C. Replace the physician's diagnosis with the diagnosis preferred by CDI
D. Ask the physician repeatedly until the desired diagnosis is documented

Question #2
Which pressure-ulcer category is specifically included in the traditional CMS HAC payment policy when the condition is not present on admission?

A. All pressure injuries regardless of stage
B. Stage 1 and stage 2 pressure ulcers
C. Stage 3 and stage 4 pressure ulcers
D. Healed pressure ulcers only

Question #3
The attending physician documents morbid obesity. A registered dietitian documents a body mass index of
43.6 kg/m² in the nutritional assessment. Which of the following is the MOST accurate statement?

A. The dietitian's BMI documentation can also establish the diagnosis of morbid obesity
B. The BMI may be obtained from the dietitian's documentation because the associated diagnosis is documented by the provider
C. Neither obesity nor BMI can be reported unless both appear in the discharge summary
D. The BMI cannot be coded because it was not documented by the physician

Question #4
A hospital reports 80 observed deaths when its risk-adjustment methodology predicted 100 expected deaths.
What is the observed-to-expected mortality ratio, and what does it indicate?

A. 0.80; observed deaths are 80% above expected
B. 1.25; observed deaths are 25% below expected
C. 0.80; observed deaths are 20% below expected
D. 1.25; observed deaths are 25% above expected

Question #5
A patient's baseline creatinine is 1.1 mg/dL. On admission it is 1.2 mg/dL, and 36 hours later it rises to 2.4 mg
/dL after prolonged hypotension. Urine output declines substantially. Which condition presents the strongest clarification opportunity?

A. End-stage renal disease
B. Chronic kidney disease
C. Nephrotic syndrome
D. Acute kidney injury

Solutions: