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ACDIS Certified Clinical Documentation Specialist Sample Questions:
At discharge, the attending physician documents, "Probable aspiration pneumonia causing the patient's respiratory symptoms." The patient is an inpatient. No subsequent documentation rules out aspiration pneumonia. How should the diagnosis be handled for inpatient coding?
- A. Code only the respiratory symptoms
- B. Code unspecified pneumonia only
- C. Code aspiration pneumonia as if established
- D. Query because "probable" diagnoses can never be coded
Correct Answer: C 🗳️
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A physician is completing rounds when a CDI specialist identifies conflicting documentation that can be clarified immediately. Which approach is MOST appropriate?
- A. Discuss the issue professionally with the physician and ensure the clarification process meets organizational query documentation requirements
- B. Wait until final billing because concurrent clarification is inappropriate
- C. Avoid verbal discussion because all queries must be electronic
- D. Tell the physician which diagnosis produces the correct MS-DRG
Correct Answer: A 🗳️
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A 34-year-old female was admitted from a group home with uncontrolled diabetes. A CDI specialist must query to specify the patient's mental incapacity since it makes management of the diabetes more difficult.
Which of the following terminology recognized by ICD-10-CM could result in the assignment of a comorbid condition?
- A. acute intellectual disability
- B. severe mental challenge
- C. severe intellectual disability
- D. acute mental incapacity
Correct Answer: C 🗳️
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Which of the following is included among the FY 2026 Hospital-Acquired Condition Reduction Program measures?
- A. Case mix index
- B. CMS PSI 90
- C. Query response rate
- D. Patient satisfaction survey completion rate
Correct Answer: B 🗳️
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A patient with an indwelling central venous catheter develops fever and positive blood cultures for Staphylococcus aureus. The physician documents "bacteremia" but does not establish whether the catheter caused the infection. Which action is MOST appropriate?
- A. Automatically code a central-line infection
- B. Query the provider regarding the relationship between the catheter and infection
- C. Code sepsis because the blood culture is positive
- D. Assume the catheter is unrelated because bacteremia was documented first
Correct Answer: B 🗳️
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