Exam Name: Certified Clinical Documentation Specialist
Certification Provider: ACDIS
Corresponding Certification: Clinical Documentation Specialist
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ACDIS Certified Clinical Documentation Specialist Sample Questions:
A CDI program plans to develop a policy for addressing diagnoses that require clinical validation. According to the Guidelines for Achieving a Compliant Query Practice, which of the following should be addressed in the policy?
- A. Include an escalation process
- B. Assign a code for any documented diagnosis
- C. Query each case retrospectively
- D. Refuse to code diagnoses without clinical support
Correct Answer: A 🗳️
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Which of the following diagnoses is classified as a major complication/comorbidity (MCC) under the FY
2026 MS-DRG system?
- A. Uncomplicated COPD
- B. Bacteremia
- C. Chronic systolic heart failure
- D. Severe protein-calorie malnutrition
Correct Answer: D 🗳️
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A physician documents obesity. A registered dietitian records a BMI of 38.4 kg/m². Which statement is MOST accurate?
- A. BMI should never be reported during an inpatient admission
- B. The BMI cannot be used because only physicians may document BMI
- C. The BMI alone allows the coder to diagnose obesity
- D. The BMI may be obtained from the dietitian's documentation when the associated diagnosis is appropriately documented
Correct Answer: D 🗳️
A patient develops a surgical-site infection after abdominal surgery and is admitted with sepsis. The surgeon clearly documents "sepsis due to postoperative wound infection." Which diagnosis category is generally sequenced first?
- A. Severe sepsis
- B. Fever
- C. The postprocedural infection code identifying the surgical-site infection
- D. The systemic sepsis code
Correct Answer: C 🗳️
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An operative report states that the surgeon performed an excisional debridement of a heel wound. The report documents removal of necrotic tissue but does not identify the deepest tissue level removed. What should the CDI specialist clarify?
- A. Deepest tissue level excised
- B. Patient's room number
- C. Number of surgical instruments used
- D. Length of anesthesia
Correct Answer: A 🗳️
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