ACDIS Certified Clinical Documentation Specialist - CCDS Exam Questions
QUESTION NO: 1
A patient is admitted with right-sided weakness and aphasia. MRI confirms an acute left cerebral infarction.
Two days later, aphasia resolves but right-sided weakness remains. The physician's documentation continues to state "TIA." What should the CDI specialist do?
A patient is admitted with right-sided weakness and aphasia. MRI confirms an acute left cerebral infarction.
Two days later, aphasia resolves but right-sided weakness remains. The physician's documentation continues to state "TIA." What should the CDI specialist do?
Correct Answer: D
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QUESTION NO: 2
A patient with abdominal pain and melena is found to have a duodenal ulcer with hemorrhage. The CDI specialist would look for clinical indicators to support which of the following conditions?
A patient with abdominal pain and melena is found to have a duodenal ulcer with hemorrhage. The CDI specialist would look for clinical indicators to support which of the following conditions?
Correct Answer: D
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QUESTION NO: 3
A patient with known heart failure presents with severe dyspnea, orthopnea, bilateral crackles, pulmonary edema, and lower-extremity edema. Echocardiography shows an ejection fraction of 28%. IV loop diuretics are administered. Which clarification is MOST clinically supported?
A patient with known heart failure presents with severe dyspnea, orthopnea, bilateral crackles, pulmonary edema, and lower-extremity edema. Echocardiography shows an ejection fraction of 28%. IV loop diuretics are administered. Which clarification is MOST clinically supported?
Correct Answer: D
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QUESTION NO: 4
A patient is admitted with hypertension and acute systolic heart failure. The provider does not explicitly link the two conditions and does not state that they are unrelated. Which coding principle applies?
A patient is admitted with hypertension and acute systolic heart failure. The provider does not explicitly link the two conditions and does not state that they are unrelated. Which coding principle applies?
Correct Answer: A
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QUESTION NO: 5
A CDI specialist submits a neutral query regarding possible acute blood loss anemia. The physician answers
"clinically unable to determine." The CDI specialist believes documenting the diagnosis would increase reimbursement substantially. What is the MOST appropriate next action?
A CDI specialist submits a neutral query regarding possible acute blood loss anemia. The physician answers
"clinically unable to determine." The CDI specialist believes documenting the diagnosis would increase reimbursement substantially. What is the MOST appropriate next action?
Correct Answer: A
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QUESTION NO: 6
At discharge, the physician documents, "Possible gram-negative pneumonia." No later documentation rules out the condition. How should the diagnosis generally be handled for an inpatient admission?
At discharge, the physician documents, "Possible gram-negative pneumonia." No later documentation rules out the condition. How should the diagnosis generally be handled for an inpatient admission?
Correct Answer: B
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QUESTION NO: 7
A patient is admitted with a documented diagnosis of acute hypoxic respiratory failure. Which of the following clinical data BEST supports the diagnosis?
A patient is admitted with a documented diagnosis of acute hypoxic respiratory failure. Which of the following clinical data BEST supports the diagnosis?
Correct Answer: A
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QUESTION NO: 8
After a month of intermittent antibiotic use, the patient is admitted. An infectious-control physician documents a diagnosis of Clostridium difficile in the inpatient medical record. Which domain of the MOST current Hospital Value-Based Purchasing program would this diagnosis impact?
After a month of intermittent antibiotic use, the patient is admitted. An infectious-control physician documents a diagnosis of Clostridium difficile in the inpatient medical record. Which domain of the MOST current Hospital Value-Based Purchasing program would this diagnosis impact?
Correct Answer: A
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QUESTION NO: 9
A CDI program is piloting a new query form to better capture the documentation of pneumonia specificity.
Which of the following would be the BEST indicator to determine the effectiveness of the query form?
A CDI program is piloting a new query form to better capture the documentation of pneumonia specificity.
Which of the following would be the BEST indicator to determine the effectiveness of the query form?
Correct Answer: B
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QUESTION NO: 10
A physician is completing rounds when a CDI specialist identifies conflicting documentation that can be clarified immediately. Which approach is MOST appropriate?
A physician is completing rounds when a CDI specialist identifies conflicting documentation that can be clarified immediately. Which approach is MOST appropriate?
Correct Answer: B
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