ACDIS CCDS

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ACDIS Certified Clinical Documentation Specialist Sample Questions:

Question #1
A CDI team identifies that orthopedic surgeons frequently document "postoperative anemia" without specifying whether blood loss is acute, expected, chronic, or clinically insignificant. What is the BEST educational strategy?

A. Stop querying postoperative anemia to reduce physician burden
B. Send surgeons a complete list of all anemia ICD-10-CM codes
C. Provide targeted education using deidentified orthopedic cases and clinically relevant documentation examples
D. Tell surgeons to document acute blood loss anemia on every postoperative patient with decreased hemoglobin

Question #2
A patient with chronic heart failure presents with confusion, nausea, and seizures. Serum sodium is 116 mEq
/L. The patient is treated with hypertonic saline and intensive electrolyte monitoring. Which diagnosis is MOST strongly supported for clarification?

A. Severe hyponatremia
B. Respiratory alkalosis
C. Hypercalcemia
D. Hypernatremia

Question #3
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?

A. Do not report pneumonia because "possible" is never reportable
B. Code the possible pneumonia as if established
C. Code unspecified pneumonia only
D. Code only cough and fever

Question #4
For FY 2026 Hospital Value-Based Purchasing, each of the four scored domains generally contributes what percentage to the Total Performance Score when all four domains are scored?

A. 40%
B. 10%
C. 25%
D. 20%

Question #5
A patient with severe cachexia and substantial loss of appetite requires pharmacologic treatment to stimulate appetite. Which of the following medications is most commonly associated with this indication?

A. Memantine
B. Sibutramine
C. Levothyroxine
D. Megestrol acetate

Solutions: