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ACDIS CCDS Exam Syllabus Topics:
| Section | Weight | Objectives |
|---|---|---|
| Topic 1: Communication skills | 9.17% | - CDI and coding roles and interdisciplinary collaboration - Physician education and effective communication |
| Topic 2: Anatomy and physiology, pathophysiology, pharmacology, and medical terminology | 19.17% | - Clinical conditions and clinical indicators - Anatomy, physiology, pathophysiology, pharmacology, and terminology |
| Topic 3: Impact of reportable diagnoses on quality of care | 8.33% | - Quality metrics, reporting programs, and financial impact - Mortality, severity of illness, and risk of mortality |
| Topic 4: Medical record documentation | 19.17% | - Documentation requirements and diagnosis or procedure code assignment - Documentation clarification and compliant physician queries |
| Topic 5: Healthcare facility CDI program analysis | 8.33% | - Data analysis, forecasting, and performance measurement - CDI productivity, provider response, CMI, and program metrics |
| Topic 6: Professionalism, ethics, and compliance | 9.17% | - Confidentiality, DRG compliance, and ethical CDI practices - Query compliance, DRG creep, and audit risks |
| Topic 7: Official Guidelines for Coding and Reporting | 14.17% | - Principal and secondary diagnosis assignment - Coding guidelines, AHA Coding Clinic, HACs, and POA indicators |
| Topic 8: Healthcare regulations, reimbursement, and documentation requirements related to the IPPS | 12.5% | - IPPS, MS-DRGs, reimbursement, and medical necessity - CC/MCC, CMI, Medicare contractors, and compliance |
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ACDIS Certified Clinical Documentation Specialist Sample Questions (Q103-Q108):
NEW QUESTION # 103
A patient without chronic hypercapnia develops severe respiratory distress. ABG results are pH 7.19, PaCO#
74 mmHg, and PaO# 60 mmHg. The patient requires emergent BiPAP. Which condition is MOST strongly supported for clarification?
- A. Metabolic alkalosis
- B. Acute hypercapnic respiratory failure
- C. Stable hypoxemia
- D. Chronic respiratory failure only
Answer: B
Explanation:
The findings strongly support clarification of acute hypercapnic respiratory failure. PaCO# of 74 mmHg represents marked carbon dioxide retention, while pH 7.19 demonstrates significant respiratory acidemia. The patient is also hypoxemic and requires urgent noninvasive ventilatory assistance.
Because there is no documented chronic hypercapnic baseline, the available information primarily supports an acute process rather than chronic respiratory failure.
Acute hypercapnia occurs when alveolar ventilation becomes insufficient to eliminate carbon dioxide.
Potential causes include COPD or asthma exacerbation, central nervous system depression, neuromuscular weakness, obesity hypoventilation, airway obstruction, or severe fatigue.
BiPAP provides positive-pressure ventilatory support and can improve alveolar ventilation, decrease work of breathing, and lower PaCO#.
The CDI specialist should not independently establish respiratory failure solely from an ABG. However, the combination of severe physiologic abnormality, respiratory distress, and escalation to BiPAP supplies a strong basis for provider clarification when no corresponding diagnosis is documented.
Metabolic alkalosis would ordinarily involve primary bicarbonate elevation with alkalemia rather than profound respiratory acidemia.
CCDS Reference Topics: Acute respiratory failure; hypercapnia; ABG interpretation; noninvasive ventilation; clinical indicators.
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NEW QUESTION # 104
Which of the following secondary diagnoses has the MOST positive monetary impact on MS-DRG reimbursement?
- A. Acute delirium
- B. Acute diastolic heart failure
- C. Acute kidney injury
- D. Acute exacerbation of COPD
Answer: B
Explanation:
Among the listed diagnoses, acute diastolic heart failure has the greatest potential MS-DRG impact because ICD-10-CM code I50.31 is classified as an MCC under the FY 2026 CMS MS-DRG system. CMS specifically identifies I50.31 as an MCC, whereas diagnoses classified only as a CC generally produce a lower severity level within DRG families that distinguish no CC/MCC, CC, and MCC cases.
Acute kidney injury, commonly represented by N17.9 when unspecified, is generally a CC rather than an MCC; CMS examples demonstrate N17.9 functioning as a CC in MS-DRG assignment. COPD with acute exacerbation and many delirium diagnoses may also affect severity assignment, but they do not exceed the MCC effect of qualifying acute heart failure in the standard hierarchy represented here.
The wording "monetary impact" must not be interpreted as permission to pursue diagnoses for financial gain.
CDI professionals should query only when clinical indicators justify clarification. Reimbursement is a consequence of accurate documentation and coding, not the clinical justification for creating a diagnosis.
The actual payment impact also depends on the principal diagnosis, existing MCCs, procedures, payer methodology, and final MS-DRG.
CCDS Reference Topics: CC/MCC hierarchy; MS-DRG reimbursement; acute heart failure; compliant CDI practice.
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NEW QUESTION # 105
A patient undergoes total knee replacement. The patient has no DVT on admission but develops a postoperative deep vein thrombosis during the hospitalization. Why is accurate POA documentation particularly important?
- A. A DVT following certain orthopedic procedures can fall within the CMS HAC payment policy
- B. POA status applies only to infectious diseases
- C. Every postoperative DVT automatically eliminates the entire hospital payment
- D. DVTs are never reportable after surgery
Answer: A
Explanation:
CMS's Hospital-Acquired Condition payment provisions include DVT and pulmonary embolism following certain orthopedic procedures, including qualifying hip and knee replacement cases. Consequently, accurate POA determination is important when a DVT occurs during the hospitalization.
If a qualifying HAC diagnosis was not present on admission, CMS's MS-DRG payment methodology may prevent the condition from generating the higher payment that its CC/MCC status would otherwise produce, subject to applicable grouper rules.
The diagnosis is still coded. Hospital-acquired status does not mean the condition disappears from the medical record or claim. The purpose of HAC payment logic is to modify payment treatment for defined conditions rather than suppress their reporting.
Nor does a single qualifying HAC necessarily eliminate the entire hospital payment. It affects how the MS- DRG is calculated in accordance with CMS rules.
CDI specialists should also distinguish the HAC/POA payment provision from the separate HAC Reduction Program. CMS explicitly identifies HACRP as a separate quality-payment program.
CCDS Reference Topics: DVT; orthopedic procedures; POA; HAC payment adjustment; MS-DRG.
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NEW QUESTION # 106
A patient undergoes colorectal surgery. On postoperative day 2, the physician documents "ileus." The record shows absent bowel sounds and abdominal distention, but the surgeon also states that delayed bowel function is expected at this stage of recovery. Which action is MOST appropriate?
- A. Assign intestinal obstruction instead
- B. Query the provider regarding whether the ileus represents an expected postoperative condition or a complication
- C. Remove the diagnosis because postoperative ileus is never reportable
- D. Automatically code postoperative ileus as a surgical complication
Answer: B
Explanation:
The record contains uncertainty regarding whether the documented ileus represents expected postoperative physiology or a clinically significant complication, making provider clarification appropriate.
Temporary impairment of gastrointestinal motility is common following abdominal surgery. Therefore, the mere occurrence of an ileus after surgery does not automatically establish a complication of care. Conversely, prolonged or clinically significant postoperative ileus requiring substantial treatment, extended hospitalization, nasogastric decompression, or other interventions may warrant distinct documentation.
The CDI specialist must not infer the complication relationship solely from timing. The Official Guidelines emphasize that a condition occurring after medical or surgical care is not automatically classified as a complication; appropriate provider documentation of the relationship and clinical significance is required where applicable.
Option C is also incorrect because postoperative ileus can be a reportable condition when clinically significant and appropriately documented. Option D substitutes a separate diagnosis without provider support.
The query should provide relevant duration, symptoms, imaging, diet status, nasogastric tube use, treatment, and expected postoperative course while allowing the surgeon to characterize the condition.
CCDS Reference Topics: Postoperative ileus; complications of care; postoperative documentation; clinical clarification.
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NEW QUESTION # 107
A patient's baseline serum creatinine is 0.9 mg/dL. Forty-eight hours after admission, the creatinine is 1.5 mg
/dL. Urine output has also decreased. Which condition is most appropriate for the CDI specialist to consider as a clarification opportunity?
- A. Nephrotic syndrome
- B. Acute kidney injury
- C. Chronic kidney disease
- D. End-stage renal disease
Answer: B
Explanation:
The laboratory trajectory strongly supports consideration of acute kidney injury (AKI). The creatinine increased from 0.9 to 1.5 mg/dL, an absolute increase of 0.6 mg/dL over 48 hours and approximately 1.67 times the baseline value. Combined with decreased urine output, this represents a clinically significant acute change in renal function.
The key distinction is the acute change from baseline. A single creatinine value cannot reliably establish AKI because renal function must be interpreted in context, including baseline creatinine, fluid status, urine output, medications, hemodynamics, and other contributing factors.
Chronic kidney disease requires evidence of persistent kidney abnormality over time rather than an isolated rapid deterioration. End-stage renal disease represents advanced irreversible kidney failure and is not supported by this scenario. Nephrotic syndrome is characterized by a different constellation including heavy proteinuria, hypoalbuminemia, and edema.
The CDI specialist should not independently diagnose AKI. Instead, the laboratory trend and reduced urine output create an appropriate basis for a provider query when no corresponding diagnosis has been documented.
CCDS Reference Topics: Renal pathophysiology; AKI clinical indicators; baseline comparison; diagnostic clarification.
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NEW QUESTION # 108
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