Certified Clinical Documentation Specialist

Question 1

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

A. Poisoning because the medication was taken incorrectly

B. No drug-related code is needed

C. Adverse effect because the drug was correctly prescribed

D. Underdosing because the therapeutic effect was excessive

Correct Answer: A

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Question 2

A patient with metastatic lung cancer is admitted solely for treatment of anemia caused by chemotherapy. The patient receives packed red blood cells and no treatment directed at the malignancy. Which diagnosis should be sequenced first?

A. Metastatic disease

B. Anemia due to chemotherapy

C. Adverse effect of chemotherapy

D. Lung cancer

Correct Answer: B

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Question 3

A patient is admitted with fever, productive cough, and hypotension. The attending physician documents sepsis due to pneumonia. Acute kidney injury develops and is documented as due to sepsis. Which of the following is the MOST appropriate sequencing concept?

A. Acute kidney injury should be the principal diagnosis

B. Severe sepsis should always be sequenced as the principal diagnosis

C. Pneumonia should be sequenced before sepsis

D. Sepsis should be sequenced first, followed by the localized infection and severe sepsis/organ dysfunction coding as applicable

Correct Answer: D

Question 4

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. Acute blood loss anemia versus another explanation for the anemia

B. Chronic iron deficiency anemia only

C. Hemolytic anemia only

D. No clarification because transfusion establishes the diagnosis

Correct Answer: A

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Question 5

Which of the following is included among the FY 2026 Hospital-Acquired Condition Reduction Program measures?

A. CMS PSI 90

B. Patient satisfaction survey completion rate

C. Case mix index

D. Query response rate

Correct Answer: A

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Question 6

CMS identifies the complete logic used to assign inpatient cases to MS-DRGs in which FY 2026 resource?

A. HCAHPS survey manual

B. Medicare Part B Physician Fee Schedule

C. MS-DRG Definitions Manual

D. National Correct Coding Initiative manual

Correct Answer: C

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Question 7

A patient is admitted with shortness of breath and dyspnea. Physical examination documents percussion dullness of the chest and decreased breath sounds. A chest x-ray indicates an increase in fluid with complete opacification of the hemithorax and mediastinal shift to the contralateral side. Which of the following conditions should be queried with the physician?

A. Pleural effusion

B. Pneumonia

C. Bronchiectasis

D. Congestive heart failure

Correct Answer: A

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Question 8

A CDI program is piloting a new query form to better capture the documentation of pneumonia specificity.
Which of the following would be the BEST indicator to determine the effectiveness of the query form?

A. Increased provider agreement rate

B. Increased volume of cases in the simple pneumonia DRGs

C. Increased volume of cases in the respiratory infection DRGs

D. Increased provider response rate

Correct Answer: C

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Question 9

A patient is admitted with hypertension and stage 3b chronic kidney disease. The physician does not explicitly state that the CKD is caused by hypertension. The record contains no documentation indicating that the two conditions are unrelated. Which of the following is the MOST appropriate approach when assigning the working diagnoses?

A. Code essential hypertension and CKD separately because the provider did not establish a relationship

B. Query the physician before recognizing hypertensive CKD

C. Code only stage 3b CKD because hypertension does not affect the MS-DRG

D. Recognize hypertensive CKD and additionally identify the CKD stage

Correct Answer: D

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Question 10

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 unspecified pneumonia only

B. Code only the respiratory symptoms

C. Code aspiration pneumonia as if established

D. Query because "probable" diagnoses can never be coded

Correct Answer: C

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Question 11

A patient experienced a type 1 STEMI 10 days ago. The patient is readmitted and develops a new type 1 NSTEMI during the four-week acute myocardial infarction period. Which ICD-10-CM concept applies?

A. The new NSTEMI is coded as chest pain because another MI cannot occur within four weeks

B. The original STEMI can no longer be reported after discharge

C. The new NSTEMI must be coded only as an old myocardial infarction

D. A subsequent myocardial infarction category may apply because a new type 1 MI occurred within four weeks of the initial qualifying MI

Correct Answer: D

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Question 12

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 cerebral ischemia

B. Cerebral infarction

C. Encephalopathy

D. Transient global amnesia

Correct Answer: B

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ACDIS Certified Clinical Documentation Specialist - CCDS Exam Practice Test

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