ACDIS Certified Clinical Documentation Specialist : CCDS

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ACDIS CCDS Exam Syllabus Topics:

ACDIS Certified Clinical Documentation Specialist Sample Questions:

Question #1
A patient with dysphagia after a recent stroke develops fever, hypoxia, and a right lower-lobe infiltrate. The physician documents "pneumonia." Speech therapy documents repeated aspiration with oral intake. What is the MOST appropriate CDI action?

A. Query the physician regarding the type or etiology of pneumonia
B. Change pneumonia to aspiration pneumonia
C. Code aspiration pneumonia from the speech therapist's documentation
D. Assign both bacterial and aspiration pneumonia

Question #2
Which CMS resource contains the complete FY 2026 lists of diagnoses classified as MCCs and CCs for MS- DRG purposes?

A. National Coverage Determination manual
B. FY 2026 IPPS Final Rule Tables, including Tables 6I and 6J
C. Medicare Physician Fee Schedule only
D. Hospital Consumer Assessment survey

Question #3
A patient has chronic gastroesophageal reflux disease listed in the past medical history. During the current hospitalization for bacterial pneumonia, GERD receives no clinical evaluation, treatment, diagnostic testing, increased nursing monitoring, or effect on length of stay. Which statement is MOST accurate?

A. GERD generally does not meet the criteria for a reportable secondary diagnosis
B. GERD must be coded because it is a chronic disease
C. GERD should be coded only if it is a CC
D. GERD must be coded because it appears in the medical record

Question #4
The progress note on hospital day 2 of a patient's admission states that the patient got up from the bed to go to the bathroom just after housekeeping had mopped the floor. The patient slipped and fell onto the floor, sustaining a broken wrist. The diagnosis of a fractured wrist will:

A. Be considered a CC for calculation of the final MS-DRG
B. Not be recognized as a CC because it was a hospital-acquired condition
C. Be coded and assigned a POA of "U"
D. Not be coded because it is a hospital-acquired condition

Question #5
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. Relative weight measures physician performance rather than resource use
C. The 2.10 DRG guarantees twice the hospital's billed charges
D. The 0.85 DRG represents a higher risk of mortality

Solutions: