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ACDIS Certified Clinical Documentation Specialist Sample Questions:

A CDI specialist drafts the following query:
"Please document acute respiratory failure because the patient's oxygen saturation is 84% and this diagnosis will qualify as an MCC." What is the MOST appropriate action?

  • A. Submit the query because the clinical indicator is valid
  • B. Remove the reimbursement language and construct a neutral clinically supported query
  • C. Submit the query only after obtaining coding-manager approval
  • D. Replace "MCC" with "CC" and submit the query
Reveal Solution  Discussion  0

Correct Answer: B  🗳️

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The attending physician documents "severe protein-calorie malnutrition." The dietitian's assessment documents normal nutritional intake, stable body weight, no fat loss, and no muscle wasting. What should the CDI specialist do?

  • A. Submit a clinical validation query
  • B. Accept the diagnosis because it was documented by the physician
  • C. Ask the dietitian to change the assessment
  • D. Delete the diagnosis
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. Acute hypercapnic respiratory failure
  • C. Chronic respiratory failure only
  • D. Stable hypoxemia
Reveal Solution  Discussion  0

Correct Answer: B  🗳️

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A physician documents "postoperative urinary retention" after surgery. The patient required temporary catheterization, but the surgeon indicates that urinary retention is a common expected consequence of anesthesia in this case. What should the CDI specialist do before treating the condition as a postoperative complication?

  • A. Automatically assign a urinary-catheter complication
  • B. Assume the condition is a complication because it followed surgery
  • C. Delete urinary retention from the record
  • D. Clarify whether the condition represents a complication or expected postoperative occurrence
Reveal Solution  Discussion  0

Correct Answer: D  🗳️

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A patient is admitted for UTI with AMS. The physician documents "UTI due to Escherichia coli." CT scan of the head is negative, with AMS improving and family reporting the patient is now at baseline. Admission creatinine is 1.2 mg/dL and sodium is 146 mEq/L. Plan is discharge home today.
The CDI specialist should query for the:

  • A. Acuity of the AMS-acute versus chronic
  • B. Reason for admission-UTI versus the diagnosis associated with the AMS
  • C. Hypernatremia as evidenced by admission serum sodium 146 mEq/L
  • D. Acute kidney failure as evidenced by admission serum creatinine 1.2 mg/dL
Reveal Solution  Discussion  0

Correct Answer: B  🗳️

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