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ACDIS Certified Clinical Documentation Specialist Sample Questions:
A patient is admitted with a stage 3 sacral pressure ulcer. During hospitalization, the wound deteriorates and is documented as stage 4 at the same site. Which reporting approach is appropriate?
- A. Use an unstageable pressure-ulcer code
- B. Report only stage 3 because that was the POA stage
- C. Report codes representing the stage on admission and the highest stage reached during the stay
- D. Report only stage 4 because it is the highest stage
Correct Answer: C 🗳️
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Which statement BEST defines the principal diagnosis for an inpatient hospitalization?
- A. The diagnosis requiring the greatest number of medications
- B. The first condition documented in the emergency department
- C. The diagnosis with the highest MS-DRG relative weight
- D. The condition established after study to be chiefly responsible for occasioning the hospital admission
Correct Answer: D 🗳️
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Which of the following is included among the FY 2026 Hospital-Acquired Condition Reduction Program measures?
- A. CMS PSI 90
- B. Query response rate
- C. Case mix index
- D. Patient satisfaction survey completion rate
Correct Answer: A 🗳️
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A hospital's case is assigned to an MS-DRG with a relative weight of 2.0000. What does the relative weight primarily indicate?
- A. The case is expected to consume approximately twice the average relative resources
- B. The hospital should bill twice its normal charges
- C. The patient is twice as sick as the average Medicare patient
- D. The patient's expected mortality is twice the national rate
Correct Answer: A 🗳️
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A patient is admitted with hypertension and stage 3b chronic kidney disease. The physician does not explicitly state that the CKD is caused by hypertension. The record contains no documentation indicating that the two conditions are unrelated. Which of the following is the MOST appropriate approach when assigning the working diagnoses?
- A. Recognize hypertensive CKD and additionally identify the CKD stage
- B. Query the physician before recognizing hypertensive CKD
- C. Code only stage 3b CKD because hypertension does not affect the MS-DRG
- D. Code essential hypertension and CKD separately because the provider did not establish a relationship
Correct Answer: A 🗳️
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