CCDS by ACDIS Actual Free Exam Questions And Answers

Question 1

Based on the AHIMA/ACDIS Practice Brief Guidelines for Achieving a Compliant Query Practice, a leading query is one that:

A. Is asked of the provider while he/she is charting in the health record with the open query

B. Lists a relevant diagnosis not documented by the provider as one of several multiple-choice options

C. Clarifies the cause-and-effect relationship of two diagnoses through a yes/no format

D. Is not supported by at least one clinical indicator/element in the health record

Discussion 0

Correct Answer: D Vote an answer

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Question 2

A patient undergoes colorectal surgery. On postoperative day 2, the physician documents "ileus." The record shows absent bowel sounds and abdominal distention, but the surgeon also states that delayed bowel function is expected at this stage of recovery. Which action is MOST appropriate?

A. Assign intestinal obstruction instead

B. Remove the diagnosis because postoperative ileus is never reportable

C. Query the provider regarding whether the ileus represents an expected postoperative condition or a complication

D. Automatically code postoperative ileus as a surgical complication

Discussion 0

Correct Answer: C Vote an answer

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Question 3

A CDI program is developing a query escalation policy. A clinically significant query remains unanswered despite normal reminders. Which action is MOST appropriate?

A. Remove the query so it cannot delay billing

B. Ask coding to choose the diagnosis instead of the provider

C. Automatically select the diagnosis most strongly supported by CDI

D. Follow the organization's defined escalation pathway

Discussion 0

Correct Answer: D Vote an answer

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Question 4

A physician documents acute kidney injury. The patient's creatinine is 0.8 mg/dL on admission, 0.9 mg/dL the following day, and 0.8 mg/dL at discharge. Urine output remains normal and no renal treatment is provided.
What is the BEST CDI action?

A. Change the diagnosis to chronic kidney disease

B. Accept acute kidney injury because the physician documented it

C. Initiate a clinical validation query

D. Remove acute kidney injury from the chart

Discussion 0

Correct Answer: C Vote an answer

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Question 5

Which statement BEST defines the principal diagnosis for an inpatient hospitalization?

A. The condition established after study to be chiefly responsible for occasioning the hospital admission

B. The diagnosis with the highest MS-DRG relative weight

C. The first condition documented in the emergency department

D. The diagnosis requiring the greatest number of medications

Discussion 0

Correct Answer: A Vote an answer

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Question 6

A hospital's query policy states that all answered queries will be retained, but all unanswered queries that might delay billing will be permanently destroyed. What is the PRIMARY compliance concern?

A. Selectively destroying unanswered queries undermines a consistent and auditable query-retention process

B. Providers should never receive written queries

C. All queries must remain in the permanent medical record forever

D. Only answered queries are legally permitted in the health record

Discussion 0

Correct Answer: A Vote an answer

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Question 7

A CDI specialist is asked to develop an educational presentation for a physician group on how documentation affects patient outcome measures within the CDI department. Which of the following is the MOST important measure to include when developing the presentation?

A. CDI/Coder agreement rates

B. number of patients reviewed monthly

C. CC/MCC capture rate

D. expected/observed mortality ratio

Discussion 0

Correct Answer: D Vote an answer

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Question 8

A patient with sepsis has acute confusion, impaired attention, fluctuating mental status, and no focal neurologic findings. CT of the head is negative. The provider documents only "AMS secondary to infection." Which clarification would be MOST clinically appropriate?

A. Cerebral infarction

B. Chronic dementia

C. Transient global amnesia

D. Acute metabolic encephalopathy

Discussion 0

Correct Answer: D Vote an answer

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Question 9

A patient accidentally takes twice the prescribed dose of warfarin and develops gastrointestinal bleeding.
Which coding concept applies?

A. Adverse effect because the drug was correctly prescribed

B. No drug-related code is needed

C. Poisoning because the medication was taken incorrectly

D. Underdosing because the therapeutic effect was excessive

Discussion 0

Correct Answer: C Vote an answer

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