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  • Total Questions: 152
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ACDIS Certified Clinical Documentation Specialist Sample Questions:

A patient with an indwelling urinary catheter develops fever, pyuria, and a positive urine culture during hospitalization. The physician documents "UTI" but does not state whether the infection is related to the catheter. What should the CDI specialist do?

  • A. Code a catheter complication whenever a urine culture is positive
  • B. Remove the UTI because catheterized patients commonly have bacteriuria
  • C. Automatically classify the UTI as catheter-associated because the catheter is present
  • D. Query the provider to clarify whether a cause-and-effect relationship exists
Reveal Solution  Discussion  0

Correct Answer: D  🗳️

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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. Ask the coder to assign the diagnosis provisionally
  • B. Query because the diagnosis changes reimbursement
  • C. Do not issue a query solely to obtain the higher-weight diagnosis
  • D. Query and list only that diagnosis as the response option
Reveal Solution  Discussion  0

Correct Answer: C  🗳️

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A patient's baseline creatinine is 1.1 mg/dL. On admission it is 1.2 mg/dL, and 36 hours later it rises to 2.4 mg
/dL after prolonged hypotension. Urine output declines substantially. Which condition presents the strongest clarification opportunity?

  • A. Acute kidney injury
  • B. End-stage renal disease
  • C. Nephrotic syndrome
  • D. Chronic kidney disease
Reveal Solution  Discussion  0

Correct Answer: A  🗳️

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A patient without chronic hypercapnia develops severe respiratory distress. ABG results are pH 7.19, PaCO#
74 mmHg, and PaO# 60 mmHg. The patient requires emergent BiPAP. Which condition is MOST strongly supported for clarification?

  • A. Metabolic alkalosis
  • B. Stable hypoxemia
  • C. Acute hypercapnic respiratory failure
  • D. Chronic respiratory failure only
Reveal Solution  Discussion  0

Correct Answer: C  🗳️

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A CDI manager finds that cardiology providers receive repeated queries for heart-failure acuity and type.
Which educational intervention is MOST appropriate?

  • A. Tell providers that unspecified heart failure reduces reimbursement
  • B. Send all providers the entire ICD-10-CM code book
  • C. Provide cardiology-specific education using the department's own documentation trends and clinical examples
  • D. Stop issuing heart-failure queries for one month
Reveal Solution  Discussion  0

Correct Answer: C  🗳️

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