ACDIS : CCDS Questions & Answers
Updated: Oct 01, 2026
No. of Questions: 152 Questions & Answers with Testing Engine
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ACDIS Certified Clinical Documentation Specialist Sample Questions:
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. Acute metabolic encephalopathy
- B. Chronic dementia
- C. Cerebral infarction
- D. Transient global amnesia
Correct Answer: A 🗳️
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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 only the respiratory symptoms
- B. Code unspecified pneumonia only
- C. Code aspiration pneumonia as if established
- D. Query because "probable" diagnoses can never be coded
Correct Answer: C 🗳️
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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. Sepsis should be sequenced first, followed by the localized infection and severe sepsis/organ dysfunction coding as applicable
- C. Pneumonia should be sequenced before sepsis
- D. Severe sepsis should always be sequenced as the principal diagnosis
Correct Answer: B 🗳️
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 volume of cases in the simple pneumonia DRGs
- B. Increased provider response rate
- C. Increased provider agreement rate
- D. Increased volume of cases in the respiratory infection DRGs
Correct Answer: D 🗳️
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What type of query is needed to compliantly address a scenario in which clinical indicators of a diagnosis exist, but for which no diagnosis has been documented in the medical record?
- A. multiple choice query
- B. cause and effect query
- C. yes or no query
- D. clinical validation query
Correct Answer: A 🗳️
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