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ACDIS Certified Clinical Documentation Specialist Sample Questions:
A 34-year-old female was admitted from a group home with uncontrolled diabetes. A CDI specialist must query to specify the patient's mental incapacity since it makes management of the diabetes more difficult.
Which of the following terminology recognized by ICD-10-CM could result in the assignment of a comorbid condition?
- A. severe intellectual disability
- B. acute mental incapacity
- C. severe mental challenge
- D. acute intellectual disability
Correct Answer: A 🗳️
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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. Present the relevant clinical indicators and offer clinically reasonable diagnostic choices, including an alternative response
- C. Wait until discharge and automatically code sepsis if antibiotics are continued
- D. "Can you confirm that the patient has sepsis? Yes or No."
Correct Answer: B 🗳️
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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. Encephalopathy
- B. Cerebral infarction
- C. Transient global amnesia
- D. Transient cerebral ischemia
Correct Answer: B 🗳️
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A patient is admitted with community-acquired pneumonia. On day 3, he begins to show signs of increasing respiratory distress and requires intubation. When he arrives in the ICU, the nurse inserts a urinary catheter and notes that his urine output has decreased. The physician documents respiratory failure and acute renal failure secondary to sepsis caused by pneumonia. The patient's condition would be classified as:
- A. severe sepsis
- B. sepsis
- C. septicemia
- D. septic shock
Correct Answer: A 🗳️
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Under the FY 2026 Hospital Value-Based Purchasing Program, hospital performance is organized into which of the following four domains?
- A. Mortality, readmissions, reimbursement, and compliance
- B. Clinical care, claims accuracy, readmissions, and utilization management
- C. Clinical outcomes, person and community engagement, safety, and efficiency and cost reduction
- D. Patient safety, documentation quality, case mix, and physician engagement
Correct Answer: C 🗳️
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