- Exam Code: CCDS
- Exam Name: Certified Clinical Documentation Specialist
- Certification Provider: ACDIS
- Corresponding Certification:Clinical Documentation Specialist
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ACDIS Certified Clinical Documentation Specialist Sample Questions:
A patient is admitted with fever and weakness. On hospital day 3, final blood cultures identify an infection that the physician documents was present at the time of admission. Which statement about present-on- admission status is MOST accurate?
- A. A condition may be POA even when it is diagnosed after admission
- B. The diagnosis cannot be POA because it was not identified until hospital day 3
- C. All diagnoses first documented after admission receive POA indicator N
- D. Only the principal diagnosis can receive POA indicator Y
Correct Answer: A 🗳️
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A wound care nurse documents an assessment and care of a pressure ulcer. For coding purposes, the wound care nurse's documentation can be used to assign which of the following?
- A. POA status
- B. Location
- C. Stage
- D. The diagnosis
Correct Answer: C 🗳️
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The attending physician documents acute respiratory failure. The patient has normal respiratory effort, oxygen saturation of 97% on room air, no supplemental oxygen requirement, and no ventilatory support. What is the MOST appropriate CDI action?
- A. Ignore the discrepancy because provider documentation can never be questioned
- B. Delete the diagnosis from the medical record
- C. Initiate a clinical validation query
- D. Change the diagnosis to hypoxemia
Correct Answer: C 🗳️
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Two MS-DRGs have relative weights of 0.85 and 2.10. Which statement is MOST accurate?
- A. The 2.10 DRG is associated with greater relative expected resource consumption
- B. The 0.85 DRG represents a higher risk of mortality
- C. The 2.10 DRG guarantees twice the hospital's billed charges
- D. Relative weight measures physician performance rather than resource use
Correct Answer: A 🗳️
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A patient has hypertension and acute on chronic diastolic heart failure documented during the same admission. The physician does not explicitly link the conditions and does not state that they are unrelated.
Which statement is MOST accurate?
- A. ICD-10-CM generally presumes a relationship between hypertension and qualifying heart disease unless documented as unrelated
- B. Hypertension should not be coded when heart failure is present
- C. A query is always required before hypertensive heart disease can be coded
- D. Only systolic heart failure can be presumed related to hypertension
Correct Answer: A 🗳️
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