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ACDIS Certified Clinical Documentation Specialist Sample Questions:
A physician documents "postoperative urinary retention" after surgery. The patient required temporary catheterization, but the surgeon indicates that urinary retention is a common expected consequence of anesthesia in this case. What should the CDI specialist do before treating the condition as a postoperative complication?
- A. Automatically assign a urinary-catheter complication
- B. Delete urinary retention from the record
- C. Assume the condition is a complication because it followed surgery
- D. Clarify whether the condition represents a complication or expected postoperative occurrence
Correct Answer: D 🗳️
Explanation: Only visible for PracticeVCE members. You can sign-up / login (it's free).
A patient is admitted with hypertension and acute systolic heart failure. The provider does not explicitly link the two conditions and does not state that they are unrelated. Which coding principle applies?
- A. A relationship may only be recognized when hypertension is the principal diagnosis
- B. Hypertension and heart failure must always be coded separately unless the physician states
"hypertensive" - C. ICD-10-CM presumes a relationship between hypertension and qualifying heart disease unless documented as unrelated
- D. Acute heart failure cannot be associated with hypertension
Correct Answer: C 🗳️
Explanation: Only visible for PracticeVCE members. You can sign-up / login (it's free).
A pregnant patient is admitted at 30 weeks' gestation with acute pyelonephritis complicating pregnancy.
Which general sequencing principle applies?
- A. Pregnancy is ignored because the infection is unrelated to delivery
- B. Pyelonephritis is always sequenced before any obstetric code
- C. A symptom code must be principal diagnosis
- D. The appropriate Chapter 15 pregnancy complication code generally receives sequencing priority
Correct Answer: D 🗳️
Explanation: Only visible for PracticeVCE members. You can sign-up / login (it's free).
A hospital's mortality report shows 125 observed deaths and 100 expected deaths. The observed-to-expected mortality ratio is 1.25. Which interpretation is MOST accurate?
- A. Observed mortality is 25% lower than expected
- B. Observed mortality is 25% higher than expected
- C. Expected mortality is 125% higher than observed
- D. The hospital's mortality performance exactly matches expected mortality
Correct Answer: B 🗳️
Explanation: Only visible for PracticeVCE members. You can sign-up / login (it's free).
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. Number of surgical instruments used
- C. Length of anesthesia
- D. Patient's room number
Correct Answer: A 🗳️
Explanation: Only visible for PracticeVCE members. You can sign-up / login (it's free).
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