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ACDIS Certified Clinical Documentation Specialist Sample Questions:
A patient accidentally takes twice the prescribed dose of warfarin and develops gastrointestinal bleeding.
Which coding concept applies?
- A. Underdosing because the therapeutic effect was excessive
- B. Adverse effect because the drug was correctly prescribed
- C. Poisoning because the medication was taken incorrectly
- D. No drug-related code is needed
Correct Answer: C 🗳️
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A patient is admitted with right-sided weakness and aphasia. MRI confirms an acute left cerebral infarction.
Two days later, aphasia resolves but right-sided weakness remains. The physician's documentation continues to state "TIA." What should the CDI specialist do?
- A. Accept TIA because it was documented first
- B. Change TIA to cerebral infarction independently
- C. Code both diagnoses without clarification
- D. Query the provider regarding cerebral infarction versus TIA based on the imaging and persistent deficit
Correct Answer: D 🗳️
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Which CMS program can reduce an eligible hospital's Medicare base operating DRG payments by as much as
3% because of excess readmissions?
- A. Hospital-Acquired Condition Reduction Program
- B. Medicare DSH Program
- C. Hospital Readmissions Reduction Program
- D. Hospital Value-Based Purchasing Program
Correct Answer: C 🗳️
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A CDI specialist reviews the MS-DRG mismatch report and notes a difference in a case. The coder noted that a current Coding Clinic affects the final coding of the record, which changed the MS-DRG assignment. To BEST understand this discrepancy, the specialist should FIRST:
- A. Discuss the case with the coder by phone or in person
- B. Review the final codes with the identified Coding Clinic
- C. Give the case to the coding manager
- D. Forward the case for billing without CDI review
Correct Answer: B 🗳️
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An arterial blood gas shows pH 7.24, PaCO# 72 mmHg, and HCO## 30 mEq/L in a patient with COPD and acute respiratory distress. Which acid-base abnormality is primarily demonstrated?
- A. Respiratory alkalosis
- B. Metabolic acidosis
- C. Metabolic alkalosis
- D. Respiratory acidosis
Correct Answer: D 🗳️
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