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ACDIS Certified Clinical Documentation Specialist Sample Questions:
A physician writes, "respiratory failure following surgery." The patient required mechanical ventilation for several hours after a prolonged major operation, and anesthesia documentation indicates this was an anticipated part of postoperative recovery. What is the BEST CDI action?
- A. Remove respiratory failure from the record
- B. Query to clarify whether the respiratory failure represents a complication or an expected postoperative condition
- C. Automatically assign a postoperative respiratory-failure complication code
- D. Code acute respiratory failure solely because mechanical ventilation occurred
Correct Answer: B 🗳️
Explanation: Only visible for Pass4suresVCE members. You can sign-up / login (it's free).
A CDI manager is evaluating physician participation in the program. Which metric most strongly indicates poor physician engagement?
- A. Number of queries generated
- B. Number of disagreed-with queries
- C. Number of agreed-with queries
- D. Number of unanswered queries
Correct Answer: D 🗳️
Explanation: Only visible for Pass4suresVCE members. You can sign-up / login (it's free).
A patient is admitted with chest pain and borderline elevation of troponins. The patient also reports a history of GERD. The physician documents that the chest pain is "likely GI in origin" and prescribes omeprazole.
Based on the clinical indicators, which of the following actions should the CDI specialist take?
- A. No query needed, chest pain is the principal diagnosis
- B. Query for chest pain due to AMI
- C. Query for the condition requiring admission
- D. No query needed, GERD is the principal diagnosis
Correct Answer: C 🗳️
Explanation: Only visible for Pass4suresVCE members. You can sign-up / login (it's free).
A patient's record contains fever, tachycardia, hypotension, positive blood cultures, and treatment with IV antibiotics and fluids. No corresponding diagnosis has been documented. Which query format is MOST appropriate?
- A. "Does the patient have sepsis? Yes or No."
- B. No query, because CDI specialists may only clarify diagnoses already documented
- C. "Please document sepsis because the clinical criteria are present."
- D. A neutral multiple-choice query presenting the clinical indicators and reasonable diagnostic alternatives
Correct Answer: D 🗳️
Explanation: Only visible for Pass4suresVCE members. You can sign-up / login (it's free).
A patient with metastatic lung cancer is admitted solely for treatment of anemia caused by chemotherapy. The patient receives packed red blood cells and no treatment directed at the malignancy. Which diagnosis should be sequenced first?
- A. Adverse effect of chemotherapy
- B. Metastatic disease
- C. Lung cancer
- D. Anemia due to chemotherapy
Correct Answer: D 🗳️
Explanation: Only visible for Pass4suresVCE members. You can sign-up / login (it's free).
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