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Free CCDS Practice Questions

10 free, exam-style Certified Clinical Documentation Specialist (CCDS) practice questions with answers and explanations. No signup required. Work through them below, then take the full free CCDS practice test to study every exam domain.

Question 1

A CDI specialist is reviewing a chart with the following clinical picture: Hgb dropped from 11.2 to 7.8 over 48 hours, the patient received 2 units PRBCs, and there is a documented melena episode. The discharge summary states only 'GI bleed.' Which query format is COMPLIANT under the 2022 AHIMA/ACDIS Guidelines for Achieving a Compliant Query Practice?

  1. A Yes/No query asking whether the patient has acute blood loss anemia, with answer choices of Yes, No, and Unable to determine - the indicators clearly support the diagnosis so a Yes/No format is the most efficient approach
  2. A multiple-choice query presenting the clinical indicators (Hgb drop, melena, transfusion) with options including acute blood loss anemia, chronic anemia, anemia unrelated to blood loss, other (please specify), and clinically undetermined
  3. A verbal query during morning rounds asking the physician to add acute blood loss anemia to the active problem list given the clinical picture, with the physician's response documented retrospectively in the CDI software only
  4. No query is needed - 'GI bleed' implicitly captures the anemia and adding a separate diagnosis would be considered double-coding under ICD-10-CM combination code conventions
Show answer & explanation

Correct answer: B - A multiple-choice query presenting the clinical indicators (Hgb drop, melena, transfusion) with options including acute blood loss anemia, chronic anemia, anemia unrelated to blood loss, other (please specify), and clinically undetermined

Question 2

A 71-year-old is admitted with pneumonia. Vitals: T 100.8°F, HR 102, RR 22, BP 118/74, SpO2 93% on 2L NC. Labs: WBC 14.2, lactate 1.6, creatinine at baseline. The patient receives ceftriaxone, azithromycin, and IV fluids; vital signs normalize within 24 hours without vasopressors. The hospitalist documents 'sepsis due to pneumonia' in the H&P and discharge summary. The payer denies the sepsis diagnosis citing Sepsis-3 criteria. What is the MOST appropriate CDI action?

  1. Remove sepsis from the working DRG because Sepsis-3 SOFA criteria are not clearly met (no vasopressors, lactate <2, rapid resolution) and the payer's denial is consistent with current peer-reviewed criteria
  2. Code sepsis as documented; the provider's clinical judgment governs and AHA Coding Clinic 4Q 2016 directs coders to rely on provider documentation regardless of which clinical criteria set is used
  3. Generate a clinical validation query asking the provider to remove the sepsis diagnosis since lactate, hemodynamics, and rapid response to standard antibiotics do not support a dysregulated host response
  4. Hold the bill and refer the case to the physician advisor for resolution before coding; sepsis denials require Sepsis-3 SOFA score documentation prior to any code assignment under current payer rules
Show answer & explanation

Correct answer: B - Code sepsis as documented; the provider's clinical judgment governs and AHA Coding Clinic 4Q 2016 directs coders to rely on provider documentation regardless of which clinical criteria set is used

Question 3

A patient is admitted with pneumonia. On hospital day 4, a Stage 3 pressure injury is identified on the sacrum. The wound nurse's note states the area was 'not assessed on admission due to patient agitation.' The physician documents 'pressure injury, present on admission status clinically undetermined.' Which POA indicator is correct, and what is the payment implication?

  1. POA = U (unknown due to insufficient documentation); treated as Y for HAC payment purposes - full DRG payment is retained because the provider acknowledged uncertainty in their documentation
  2. POA = W (clinically undetermined); treated as N for HAC payment purposes - the additional payment for the Stage 3 pressure injury is denied as a hospital-acquired condition under CMS rules
  3. POA = U (unknown due to insufficient documentation); treated as N for HAC payment purposes - additional payment denied due to inadequate documentation at the time of admission assessment
  4. POA = W (clinically undetermined); treated as Y for HAC payment purposes - full payment retained because the provider's clinical judgment governs and W reflects clinical uncertainty rather than missing documentation
Show answer & explanation

Correct answer: D - POA = W (clinically undetermined); treated as Y for HAC payment purposes - full payment retained because the provider's clinical judgment governs and W reflects clinical uncertainty rather than missing documentation

Question 4

An 82-year-old is admitted with shortness of breath. Echo: LV ejection fraction 28%, moderate diastolic dysfunction. BNP 2,140. CXR: pulmonary congestion. Treatment: IV furosemide drip, oral metoprolol, sacubitril-valsartan. Discharge summary states 'CHF exacerbation, return to dry weight achieved.' The patient has prior echo from 2 years ago showing EF 30%. Which query is MOST appropriate?

  1. A Yes/No query asking whether the patient has acute on chronic systolic heart failure, with answer choices Yes, No, and Unable to determine - the EF and treatment unambiguously support this specific diagnosis
  2. No query is needed - 'CHF exacerbation' is sufficient documentation because the prior echo establishes chronic systolic dysfunction and the treatment plan implies acute decompensation
  3. A multiple-choice query with options including acute on chronic systolic (HFrEF), acute on chronic diastolic (HFpEF), acute on chronic combined systolic/diastolic, chronic systolic stable, other (please specify), and clinically undetermined
  4. An open-ended query asking the provider to please specify the heart failure diagnosis in greater detail before discharge, including type, acuity, and any contributing precipitants identified during the admission
Show answer & explanation

Correct answer: C - A multiple-choice query with options including acute on chronic systolic (HFrEF), acute on chronic diastolic (HFpEF), acute on chronic combined systolic/diastolic, chronic systolic stable, other (please specify), and clinically undetermined

Question 5

A patient is admitted for evaluation of right-sided weakness. The discharge summary documents 'probable acute ischemic stroke vs. complicated migraine.' MRI was contraindicated; CT was non-diagnostic. The patient was treated with aspirin and discharged with neurology follow-up. According to ICD-10-CM Official Guidelines for Coding and Reporting, how should the principal diagnosis be coded?

  1. Code the symptom (right-sided weakness, R29.810) as principal because the underlying diagnosis was never definitively established by imaging or clinical confirmation during the inpatient stay
  2. Do not code either condition; generate a retrospective query asking the provider to establish certainty regarding stroke versus migraine before the bill is submitted to the payer
  3. Code acute ischemic stroke as if confirmed because Section II.H instructs that uncertain diagnoses (probable, suspected, likely, possible, consistent with) at the time of inpatient discharge are coded as if established
  4. Code complicated migraine as principal because acute ischemic stroke was not confirmed on imaging and the lower-acuity diagnosis must be selected when imaging is non-diagnostic
Show answer & explanation

Correct answer: C - Code acute ischemic stroke as if confirmed because Section II.H instructs that uncertain diagnoses (probable, suspected, likely, possible, consistent with) at the time of inpatient discharge are coded as if established

Question 6

A 64-year-old admitted for cellulitis has the following creatinine trend: baseline 0.9 (from outpatient labs 3 weeks prior), admission 1.3, day 2: 1.6, day 3: 1.5, day 5: 1.0. Urine output was adequate throughout. The patient received IV fluids and IV antibiotics. The hospitalist documents 'acute renal insufficiency, resolved with hydration.' For accurate severity capture and code assignment, what is the MOST appropriate CDI action?

  1. No query needed - 'acute renal insufficiency' will appropriately map to N17.9 (acute kidney failure, unspecified, a CC) and the documented resolution supports the clinical course
  2. Query the provider: clinical indicators meet KDIGO Stage 1 AKI criteria (creatinine increase ≥1.5× baseline within 7 days); 'acute renal insufficiency' does not equate to AKI in ICD-10-CM and the appropriate diagnosis (AKI vs. ATN vs. other) should be clarified
  3. Code N17.0 (acute kidney failure with acute tubular necrosis, an MCC) based on the creatinine pattern and rapid response to fluids, which together support a presumptive diagnosis of pre-renal ATN
  4. Query whether the patient has chronic kidney disease since the baseline creatinine of 0.9 may represent the patient's normal function and the admission creatinine of 1.3 may represent baseline rather than acute injury
Show answer & explanation

Correct answer: B - Query the provider: clinical indicators meet KDIGO Stage 1 AKI criteria (creatinine increase ≥1.5× baseline within 7 days); 'acute renal insufficiency' does not equate to AKI in ICD-10-CM and the appropriate diagnosis (AKI vs. ATN vs. other) should be clarified

Question 7

A CDI specialist drafts the following query for a patient with Hgb 7.4, two units PRBCs transfused, and a documented active GI bleed: 'Based on the Hgb of 7.4, transfusion of 2 units PRBCs, and active hematochezia, please document acute blood loss anemia.' Which statement BEST evaluates this query under the 2022 AHIMA/ACDIS Compliant Query Practice Guidelines?

  1. The query is compliant because the clinical indicators clearly support the suggested diagnosis and the brief permits queries that direct providers when the clinical picture leaves only one realistic answer
  2. The query is compliant because 'acute blood loss anemia' is the only realistic clinical answer given the indicators, and additional answer choices would be artificial and could create confusion for the provider
  3. The query is non-compliant because it is leading - it directs the provider to a single specific diagnosis rather than presenting clinical indicators with multiple-choice options including 'other' and 'clinically undetermined'
  4. The query is non-compliant only because it omits an explicit option for the provider to disagree with the suggested diagnosis or document an alternative they consider more clinically appropriate
Show answer & explanation

Correct answer: C - The query is non-compliant because it is leading - it directs the provider to a single specific diagnosis rather than presenting clinical indicators with multiple-choice options including 'other' and 'clinically undetermined'

Question 8

A patient is grouped to MS-DRG 195 (Simple Pneumonia & Pleurisy w/o CC/MCC, relative weight ~0.7096). Documentation review reveals the patient received BiPAP for hypercapnic respiratory failure (ABG: pH 7.31, pCO2 58, pO2 62 on 4L NC), which was not coded. After a successful query, acute hypercapnic respiratory failure (J96.02, MCC) is added, moving the case to MS-DRG 193 (Simple Pneumonia & Pleurisy w/ MCC, relative weight ~1.4423). At a hospital base rate of $6,500, what is the approximate financial impact of this single documentation capture?

  1. Approximately $2,300 - calculated as the relative weight difference applied to a partial base rate after standard CMS adjustments for wage index, IME, and DSH percentages
  2. Approximately $4,763 - the difference between the relative weights (1.4423 − 0.7096 = 0.7327) multiplied by the hospital base rate ($6,500)
  3. Approximately $9,375 - the full payment for MS-DRG 193 (relative weight 1.4423 × base rate $6,500), which replaces the original DRG payment in its entirety after recoding
  4. There is no payment difference because both DRGs are within the same MDC and CMS pays a single rate per episode regardless of severity tier under the current IPPS methodology
Show answer & explanation

Correct answer: B - Approximately $4,763 - the difference between the relative weights (1.4423 − 0.7096 = 0.7327) multiplied by the hospital base rate ($6,500)

Question 9

A 67-year-old underwent elective total knee arthroplasty. On postoperative day 2, the patient developed acute hypoxemic respiratory failure (PaO2 52 on RA, requiring BiPAP). The condition was not present on admission. Which AHRQ Patient Safety Indicator is at risk, and what is the BEST CDI strategy to ensure appropriate quality reporting?

  1. PSI-11 (Postoperative Respiratory Failure), the highest-weighted PSI 90 component; ensure POA = N is accurately assigned and capture any documented measure exclusions (e.g., preexisting neuromuscular disease, chronic respiratory failure, certain trauma cases)
  2. PSI-04 (Death Rate Among Surgical Inpatients with Serious Treatable Complications); document the respiratory failure as POA = Y to avoid the PSI hit and lower the hospital's expected mortality denominator
  3. PSI-09 (Postoperative Hemorrhage or Hematoma); query the surgeon to clarify whether the respiratory failure represents a hemorrhagic complication of the procedure that should be reported under this PSI
  4. No PSI is at risk because the patient survived the event; PSI 90 components only count cases resulting in fatal complications or extended LOS over 30 days under the current AHRQ specifications
Show answer & explanation

Correct answer: A - PSI-11 (Postoperative Respiratory Failure), the highest-weighted PSI 90 component; ensure POA = N is accurately assigned and capture any documented measure exclusions (e.g., preexisting neuromuscular disease, chronic respiratory failure, certain trauma cases)

Question 10

A 78-year-old admitted with pneumonia has the following findings: BMI 18.2, documented unintentional weight loss of 8% over 3 months, reduced oral intake at 40% of estimated needs for >5 days, visible temporal wasting on exam, and grip strength below age-adjusted norms. Albumin is 2.6 g/dL. The dietitian documents 'severe protein-calorie malnutrition per ASPEN criteria.' The provider's notes mention only 'poor appetite.' Which CDI action is MOST appropriate?

  1. Code E43 (severe malnutrition, MCC) directly from the dietitian's note since ASPEN criteria are clearly met, the albumin of 2.6 confirms the diagnosis, and the dietitian is the clinical expert on nutrition diagnoses
  2. No query needed - albumin <3.5 g/dL is sufficient evidence of protein-calorie malnutrition and the dietitian's documentation provides adequate supporting clinical context for direct code assignment
  3. Query the provider to address the dietitian's malnutrition findings; albumin and prealbumin are NOT defining nutrition markers (they are negative acute-phase reactants reflecting inflammation) and the provider - not the dietitian alone - must document the diagnosis for code assignment
  4. Query the dietitian to clarify the severity grade (mild, moderate, severe) before coding so that the appropriate ICD-10-CM code (E44.1, E44.0, or E43) can be assigned to the encounter
Show answer & explanation

Correct answer: C - Query the provider to address the dietitian's malnutrition findings; albumin and prealbumin are NOT defining nutrition markers (they are negative acute-phase reactants reflecting inflammation) and the provider - not the dietitian alone - must document the diagnosis for code assignment

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