ACDIS Certified Clinical Documentation Specialist : CCDS

CCDS real exams

Exam Code: CCDS

Exam Name: Certified Clinical Documentation Specialist

Updated: Sep 28, 2026

Q & A: 152 Questions and Answers

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ACDIS Certified Clinical Documentation Specialist Sample Questions:

Question #1

A patient with sepsis has acute confusion, impaired attention, fluctuating mental status, and no focal neurologic findings. CT of the head is negative. The provider documents only "AMS secondary to infection." Which clarification would be MOST clinically appropriate?

  • A. Acute metabolic encephalopathy
  • B. Cerebral infarction
  • C. Transient global amnesia
  • D. Chronic dementia
Reveal Solution  Discussion  0

Correct Answer: A  🗳️

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Question #2

A CDI specialist sends a compliant query. The physician answers "other-viral syndrome" and supports the diagnosis in the progress note. The queried diagnosis would have been an MCC. What should the CDI specialist do?

  • A. Accept the clinically supported provider response
  • B. Reissue the same query until the provider selects the MCC
  • C. Ask coding to assign the MCC anyway
  • D. Reject the answer because it does not produce an MCC
Reveal Solution  Discussion  0

Correct Answer: A  🗳️

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Question #3

The amount of the IPPS Indirect Medical Education Adjustment is determined by teaching intensity as measured by the hospital's number of residents compared to:

  • A. ED and inpatient beds
  • B. Inpatient beds
  • C. Disproportionate payment rates
  • D. Number of admissions
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Correct Answer: B  🗳️

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Question #4

A patient has chronic gastroesophageal reflux disease listed in the past medical history. During the current hospitalization for bacterial pneumonia, GERD receives no clinical evaluation, treatment, diagnostic testing, increased nursing monitoring, or effect on length of stay. Which statement is MOST accurate?

  • A. GERD generally does not meet the criteria for a reportable secondary diagnosis
  • B. GERD must be coded because it is a chronic disease
  • C. GERD should be coded only if it is a CC
  • D. GERD must be coded because it appears in the medical record
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Correct Answer: A  🗳️

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Question #5

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 aspiration pneumonia as POA
  • C. Query for sepsis as POA
  • D. Sepsis is the principal diagnosis, no query needed
Reveal Solution  Discussion  0

Correct Answer: C  🗳️

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