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ACDIS Certified Clinical Documentation Specialist Sample Questions:

A CDI specialist reviews a prior hospitalization and finds that the patient previously had chronic systolic heart failure. During the current admission, the provider documents only "history of CHF," although the patient remains on long-term heart-failure therapy. What is the BEST approach?

  • A. Ignore all prior-encounter information under every circumstance
  • B. Use prior documentation as clinically relevant context but obtain current provider clarification when the diagnosis materially affects the present record
  • C. Automatically copy chronic systolic heart failure into the current encounter
  • D. Assign acute systolic heart failure because the diagnosis appeared previously
Reveal Solution  Discussion  0

Correct Answer: B  🗳️

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A patient was admitted with weakness, loss of appetite, hemoglobin 7.8, WBC 2,700, and platelet count 58.
The admitting diagnoses on the history and physical were anemia, leukopenia, decreased platelets, and rule out myelodysplastic syndrome. Based on these clinical indicators a CDI specialist should query for which of the following conditions?

  • A. myelophthisis
  • B. pancytopenia
  • C. aplastic anemia
  • D. thrombocytopenia
Reveal Solution  Discussion  0

Correct Answer: B  🗳️

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A patient is admitted with sepsis due to osteomyelitis and evidence of organ failure. Which of the following is the correct principal diagnosis?

  • A. Sepsis
  • B. Severe sepsis
  • C. Unspecified septicemia
  • D. Osteomyelitis
Reveal Solution  Discussion  0

Correct Answer: A  🗳️

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A patient who underwent abdominal surgery one week ago is readmitted specifically for treatment of a postoperative wound infection documented by the surgeon as a complication of the procedure. Which condition should generally be considered for principal diagnosis selection?

  • A. The original condition that required surgery
  • B. The postoperative wound infection/complication
  • C. Abdominal pain
  • D. Fever
Reveal Solution  Discussion  0

Correct Answer: B  🗳️

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A CDI program is developing a query escalation policy. A clinically significant query remains unanswered despite normal reminders. Which action is MOST appropriate?

  • A. Follow the organization's defined escalation pathway
  • B. Ask coding to choose the diagnosis instead of the provider
  • C. Automatically select the diagnosis most strongly supported by CDI
  • D. Remove the query so it cannot delay billing
Reveal Solution  Discussion  0

Correct Answer: A  🗳️

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