ACDIS CCDS

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ACDIS CCDS Exam Syllabus Topics:

ACDIS Certified Clinical Documentation Specialist Sample Questions:

Question #1
A patient's baseline creatinine is 1.0 mg/dL. Following prolonged hypotension, creatinine rises to 3.8 mg/dL.
Urinalysis demonstrates granular casts, and the nephrologist documents "acute renal failure" but does not specify the underlying renal lesion. Which condition would be MOST appropriate to consider in a clinically supported clarification query?

A. Acute tubular necrosis
B. Nephrotic syndrome
C. Chronic kidney disease stage 5
D. Pyelonephritis

Question #2
Respiratory failure is documented in a patient's initial progress notes. There are no clinical indicators in the record to support this diagnosis. According to the AHIMA/ACDIS Practice Brief Guidelines for Achieving a Compliant Query Practice, the MOST appropriate action by the CDI specialist is which of the following?

A. Do not assign a code for respiratory failure
B. Review for documentation of CPAP to support respiratory failure
C. Assign a code for respiratory failure
D. Query the provider for validation of the diagnosis

Question #3
A CDI program plans to develop a policy for addressing diagnoses that require clinical validation. According to the Guidelines for Achieving a Compliant Query Practice, which of the following should be addressed in the policy?

A. Refuse to code diagnoses without clinical support
B. Query each case retrospectively
C. Include an escalation process
D. Assign a code for any documented diagnosis

Question #4
A physician documents "postoperative urinary retention" after surgery. The patient required temporary catheterization, but the surgeon indicates that urinary retention is a common expected consequence of anesthesia in this case. What should the CDI specialist do before treating the condition as a postoperative complication?

A. Assume the condition is a complication because it followed surgery
B. Automatically assign a urinary-catheter complication
C. Clarify whether the condition represents a complication or expected postoperative occurrence
D. Delete urinary retention from the record

Question #5
A hospital has 2,500 inpatient discharges and a cumulative MS-DRG relative weight of 4,375. What is the hospital's case mix index?

A. 2.50
B. 1.75
C. 0.57
D. 1.25

Solutions: