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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 aspiration pneumonia as if established
- C. Query because "probable" diagnoses can never be coded
- D. Code unspecified pneumonia only
Correct Answer: B 🗳️
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Which CMS resource contains the complete FY 2026 lists of diagnoses classified as MCCs and CCs for MS- DRG purposes?
- A. Hospital Consumer Assessment survey
- B. National Coverage Determination manual
- C. Medicare Physician Fee Schedule only
- D. FY 2026 IPPS Final Rule Tables, including Tables 6I and 6J
Correct Answer: D 🗳️
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A patient is admitted with TIA, right-sided weakness, and slurred speech. The physician's physical examination notes that the patient's right-sided weakness continues, but the slurred speech has resolved. A CT scan of the brain reveals a new hypodense area. The most specific diagnosis to query is acute:
- A. Transient global amnesia
- B. Encephalopathy
- C. Transient cerebral ischemia
- D. Cerebral infarction
Correct Answer: D 🗳️
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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 must be coded because it is a chronic disease
- B. GERD generally does not meet the criteria for a reportable secondary diagnosis
- C. GERD should be coded only if it is a CC
- D. GERD must be coded because it appears in the medical record
Correct Answer: B 🗳️
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A CDI specialist identifies fever, leukocytosis, tachycardia, positive blood cultures, and IV antibiotic treatment. No infectious diagnosis has been documented. Which query approach is MOST compliant?
- A. "Please document sepsis because the patient meets sepsis criteria."
- B. Wait until discharge and automatically code sepsis if antibiotics are continued
- C. "Can you confirm that the patient has sepsis? Yes or No."
- D. Present the relevant clinical indicators and offer clinically reasonable diagnostic choices, including an alternative response
Correct Answer: D 🗳️
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