ACDIS CCDS : Certified Clinical Documentation Specialist

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ACDIS Certified Clinical Documentation Specialist Sample Questions:

Question #1
An operative report states that the surgeon performed an excisional debridement of a heel wound. The report documents removal of necrotic tissue but does not identify the deepest tissue level removed. What should the CDI specialist clarify?

A. Length of anesthesia
B. Number of surgical instruments used
C. Patient's room number
D. Deepest tissue level excised

Question #2
Which of the following conditions demonstrates the greatest risk of mortality in a 77-year-old patient?

A. History of hypertension and diabetes mellitus, admitted with NSTEMI with acute systolic heart failure
B. History of tobacco use, admitted with COPD exacerbation and respiratory failure
C. History of mastectomy 10 years ago, admitted with sepsis and a UTI
D. History of diabetes mellitus, admitted with UTI and metabolic encephalopathy

Question #3
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. Tell surgeons to document acute blood loss anemia on every postoperative patient with decreased hemoglobin
C. Provide targeted education using deidentified orthopedic cases and clinically relevant documentation examples
D. Send surgeons a complete list of all anemia ICD-10-CM codes

Question #4
A patient is admitted with shortness of breath and dyspnea. Physical examination documents percussion dullness of the chest and decreased breath sounds. A chest x-ray indicates an increase in fluid with complete opacification of the hemithorax and mediastinal shift to the contralateral side. Which of the following conditions should be queried with the physician?

A. Bronchiectasis
B. Pneumonia
C. Pleural effusion
D. Congestive heart failure

Question #5
A patient with COPD normally has a PaCO# of approximately 45 mmHg. The patient is admitted with increasing somnolence and respiratory distress. Arterial blood gas results are pH 7.27, PaCO# 68 mmHg, and PaO# 58 mmHg. BiPAP is initiated. Which condition is MOST appropriate for the CDI specialist to consider as a clarification opportunity?

A. Metabolic acidosis
B. Acute hypercapnic respiratory failure
C. Chronic respiratory failure only
D. Stable COPD without respiratory failure

Solutions: