Certified Clinical Documentation Specialist: CCDS Exam
"Certified Clinical Documentation Specialist", also known as CCDS exam, is a ACDIS Certification. With the complete collection of questions and answers, PrepAwayPDF has assembled to take you through 152 Q&As to your CCDS Exam preparation. In the CCDS exam resources, you will cover every field and category in Clinical Documentation Specialist Certification helping to ready you for your successful ACDIS Certification.
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ACDIS Certified Clinical Documentation Specialist Sample Questions:
A patient with dysphagia after a recent stroke develops fever, hypoxia, and a right lower-lobe infiltrate. The physician documents "pneumonia." Speech therapy documents repeated aspiration with oral intake. What is the MOST appropriate CDI action?
- A. Code aspiration pneumonia from the speech therapist's documentation
- B. Change pneumonia to aspiration pneumonia
- C. Assign both bacterial and aspiration pneumonia
- D. Query the physician regarding the type or etiology of pneumonia
Correct Answer: D 🗳️
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A patient with COPD normally has a PaCO# of approximately 45 mmHg. The patient is admitted with increasing somnolence and respiratory distress. Arterial blood gas results are pH 7.27, PaCO# 68 mmHg, and PaO# 58 mmHg. BiPAP is initiated. Which condition is MOST appropriate for the CDI specialist to consider as a clarification opportunity?
- A. Chronic respiratory failure only
- B. Acute hypercapnic respiratory failure
- C. Stable COPD without respiratory failure
- D. Metabolic acidosis
Correct Answer: B 🗳️
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A patient's past medical history lists remote peptic ulcer disease. During the current admission, the condition receives no evaluation, treatment, diagnostic workup, extended length of stay, or increased nursing monitoring. Which statement is MOST accurate?
- A. It must be reported because all past medical-history conditions are secondary diagnoses
- B. It automatically qualifies as a CC because it is a chronic condition
- C. It should be reported because it appears in the medical record
- D. It generally does not meet the criteria for a reportable additional diagnosis
Correct Answer: D 🗳️
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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. Sepsis is the principal diagnosis, no query needed
- B. Query for aspiration pneumonia as POA
- C. Query for sepsis as POA
- D. Pneumonia is the principal diagnosis; no query needed
Correct Answer: C 🗳️
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A patient with a history of heart failure is admitted with severe dyspnea and bilateral lower-extremity edema.
BNP is 1,000 pg/mL and echocardiography shows an ejection fraction of 25% with left ventricular systolic dysfunction. Which diagnosis should the CDI specialist consider when constructing a clinically supported clarification query?
- A. Acute on chronic diastolic heart failure
- B. Acute on chronic systolic heart failure
- C. Combined systolic and diastolic heart failure
- D. Chronic systolic heart failure
Correct Answer: B 🗳️
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