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ACDIS Certified Clinical Documentation Specialist Sample Questions:
CMS identifies the complete logic used to assign inpatient cases to MS-DRGs in which FY 2026 resource?
- A. Medicare Part B Physician Fee Schedule
- B. MS-DRG Definitions Manual
- C. National Correct Coding Initiative manual
- D. HCAHPS survey manual
Correct Answer: B 🗳️
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A patient presents with fever, productive cough, and infiltrates in the right upper lobe per chest x-ray. The history and physical notes that the patient has pneumonia and hypotension. Cultures are drawn and the patient is admitted for IV antibiotics. On day 2, the patient's condition worsens, and the patient is transferred to the ICU for closer monitoring. The ICU physician documents sepsis. Which of the following statements is MOST accurate?
- A. Query for sepsis as POA
- B. Sepsis is the principal diagnosis, no query needed
- C. Query for aspiration pneumonia as POA
- D. Pneumonia is the principal diagnosis; no query needed
Correct Answer: A 🗳️
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An arterial blood gas shows pH 7.24, PaCO# 72 mmHg, and HCO## 30 mEq/L in a patient with COPD and acute respiratory distress. Which acid-base abnormality is primarily demonstrated?
- A. Respiratory acidosis
- B. Metabolic alkalosis
- C. Respiratory alkalosis
- D. Metabolic acidosis
Correct Answer: A 🗳️
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After a month of intermittent antibiotic use, the patient is admitted. An infectious-control physician documents a diagnosis of Clostridium difficile in the inpatient medical record. Which domain of the MOST current Hospital Value-Based Purchasing program would this diagnosis impact?
- A. Clinical care
- B. PSI 90 data
- C. Hospital-acquired infection
- D. Safety outcome
Correct Answer: D 🗳️
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A patient's hemoglobin decreases from 13.1 g/dL before surgery to 7.4 g/dL afterward. Estimated intraoperative blood loss is 1,200 mL, and the patient receives two units of packed red blood cells. The physician documents only "postoperative anemia." Which clarification is MOST appropriate?
- A. Hemolytic anemia only
- B. Chronic iron deficiency anemia only
- C. No clarification because transfusion establishes the diagnosis
- D. Acute blood loss anemia versus another explanation for the anemia
Correct Answer: D 🗳️
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