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ACDIS Certified Clinical Documentation Specialist Sample Questions:
A patient with cirrhosis presents with confusion and asterixis. Ammonia is elevated and the patient improves after lactulose administration. The physician documents "altered mental status due to liver disease." Which clarification would provide the MOST clinically specific documentation?
- A. Hepatic encephalopathy
- B. Dementia
- C. Metabolic acidosis
- D. Alcohol withdrawal
Correct Answer: A 🗳️
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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. Osteomyelitis
- B. Severe sepsis
- C. Unspecified septicemia
- D. Sepsis
Correct Answer: D 🗳️
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A patient is admitted with shortness of breath and dyspnea. Physical examination documents percussion dullness of the chest and decreased breath sounds. A chest x-ray indicates an increase in fluid with complete opacification of the hemithorax and mediastinal shift to the contralateral side. Which of the following conditions should be queried with the physician?
- A. Pneumonia
- B. Bronchiectasis
- C. Congestive heart failure
- D. Pleural effusion
Correct Answer: D 🗳️
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A patient with an indwelling urinary catheter develops fever, pyuria, and a positive urine culture during hospitalization. The physician documents "UTI" but does not state whether the infection is related to the catheter. What should the CDI specialist do?
- A. Query the provider to clarify whether a cause-and-effect relationship exists
- B. Code a catheter complication whenever a urine culture is positive
- C. Remove the UTI because catheterized patients commonly have bacteriuria
- D. Automatically classify the UTI as catheter-associated because the catheter is present
Correct Answer: A 🗳️
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A CDI manager is evaluating physician participation in the program. Which metric most strongly indicates poor physician engagement?
- A. Number of queries generated
- B. Number of disagreed-with queries
- C. Number of agreed-with queries
- D. Number of unanswered queries
Correct Answer: D 🗳️
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