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ACDIS Certified Clinical Documentation Specialist Sample Questions:
A hospital's case is assigned to an MS-DRG with a relative weight of 2.0000. What does the relative weight primarily indicate?
- A. The hospital should bill twice its normal charges
- B. The patient's expected mortality is twice the national rate
- C. The case is expected to consume approximately twice the average relative resources
- D. The patient is twice as sick as the average Medicare patient
Correct Answer: C 🗳️
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A patient is admitted with alcohol intoxication. The H & P notes increased tolerance related to alcohol consumption, desire to drink despite impaired liver functions, and unsuccessful attempts to stop drinking.
Identify the query opportunity related to alcohol consumption.
- A. Withdrawal
- B. Dependence
- C. Delirium tremens
- D. Abuse
Correct Answer: B 🗳️
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A patient with severe cachexia and substantial loss of appetite requires pharmacologic treatment to stimulate appetite. Which of the following medications is most commonly associated with this indication?
- A. Memantine
- B. Megestrol acetate
- C. Levothyroxine
- D. Sibutramine
Correct Answer: B 🗳️
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A patient is admitted with chest pain and borderline elevation of troponins. The patient also reports a history of GERD. The physician documents that the chest pain is "likely GI in origin" and prescribes omeprazole.
Based on the clinical indicators, which of the following actions should the CDI specialist take?
- A. No query needed, GERD is the principal diagnosis
- B. Query for chest pain due to AMI
- C. Query for the condition requiring admission
- D. No query needed, chest pain is the principal diagnosis
Correct Answer: C 🗳️
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A patient has hypertension and acute on chronic diastolic heart failure documented during the same admission. The physician does not explicitly link the conditions and does not state that they are unrelated.
Which statement is MOST accurate?
- A. Only systolic heart failure can be presumed related to hypertension
- B. A query is always required before hypertensive heart disease can be coded
- C. ICD-10-CM generally presumes a relationship between hypertension and qualifying heart disease unless documented as unrelated
- D. Hypertension should not be coded when heart failure is present
Correct Answer: C 🗳️
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