ACDIS : CCDS Questions & Answers
Last Updated: Oct 06, 2026
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ACDIS Certified Clinical Documentation Specialist Sample Questions:
A patient with cirrhosis presents with confusion and asterixis. Ammonia is elevated and the patient improves after lactulose administration. The physician documents "altered mental status due to liver disease." Which clarification would provide the MOST clinically specific documentation?
- A. Hepatic encephalopathy
- B. Dementia
- C. Metabolic acidosis
- D. Alcohol withdrawal
Correct Answer: A 🗳️
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A neurologist documents acute cerebral infarction. A qualified stroke nurse records the NIH Stroke Scale score in the medical record. Which statement is MOST accurate?
- A. NIHSS scores are not reportable in ICD-10-CM
- B. The NIHSS score may be obtained from qualified non-provider documentation when the related diagnosis is documented by the provider
- C. The NIHSS score cannot be coded unless repeated by the physician
- D. The nurse's NIHSS documentation establishes the cerebral infarction diagnosis independently
Correct Answer: B 🗳️
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A CDI specialist identifies a diagnosis that would change the case from a lower-weight MS-DRG to a higher- weight MS-DRG. The medical record contains no clinical indicators supporting that diagnosis. What is the BEST action?
- A. Do not issue a query solely to obtain the higher-weight diagnosis
- B. Query and list only that diagnosis as the response option
- C. Ask the coder to assign the diagnosis provisionally
- D. Query because the diagnosis changes reimbursement
Correct Answer: A 🗳️
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A pregnant patient is admitted at 30 weeks' gestation with acute pyelonephritis complicating pregnancy.
Which general sequencing principle applies?
- A. The appropriate Chapter 15 pregnancy complication code generally receives sequencing priority
- B. A symptom code must be principal diagnosis
- C. Pyelonephritis is always sequenced before any obstetric code
- D. Pregnancy is ignored because the infection is unrelated to delivery
Correct Answer: A 🗳️
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A patient presents with fever, productive cough, and infiltrates in the right upper lobe per chest x-ray. The history and physical notes that the patient has pneumonia and hypotension. Cultures are drawn and the patient is admitted for IV antibiotics. On day 2, the patient's condition worsens, and the patient is transferred to the ICU for closer monitoring. The ICU physician documents sepsis. Which of the following statements is MOST accurate?
- A. Pneumonia is the principal diagnosis; no query needed
- B. Query for sepsis as POA
- C. Sepsis is the principal diagnosis, no query needed
- D. Query for aspiration pneumonia as POA
Correct Answer: B 🗳️
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