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  • Total Questions: 152
  • Updated on: Sep 28, 2026
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  • Total Questions: 152
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  • Total Questions: 152
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ACDIS Certified Clinical Documentation Specialist Sample Questions:

A patient with active breast cancer is admitted solely to receive a scheduled cycle of antineoplastic chemotherapy. No complication or acute disease process is responsible for the admission. Which diagnosis is generally sequenced first?

  • A. Breast cancer
  • B. Encounter for antineoplastic chemotherapy
  • C. Malignancy-related fatigue
  • D. Immunosuppression
Reveal Solution  Discussion  0

Correct Answer: B  🗳️

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A patient is admitted with nausea, confusion, and generalized weakness. Laboratory testing shows a serum sodium level of 119 mEq/L. The patient receives hypertonic saline and frequent serum sodium monitoring.
The physician documents "electrolyte disturbance." Which condition is the MOST appropriate clarification opportunity?

  • A. Hyperkalemia
  • B. Hypernatremia
  • C. Metabolic alkalosis
  • D. Hyponatremia
Reveal Solution  Discussion  0

Correct Answer: D  🗳️

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A patient is admitted with confusion and a history of alcoholic cirrhosis. Ammonia level is 100 µ/L and the blood alcohol level is 2.9. Based on these clinical indicators, the CDI specialist should query the physician for which of the following conditions?

  • A. ETOH dependence
  • B. Alcohol poisoning
  • C. Delirium
  • D. Hepatic failure
Reveal Solution  Discussion  0

Correct Answer: D  🗳️

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A patient is admitted with a stage 4 pressure ulcer of the right heel. The physician documents the pressure- ulcer diagnosis and location. The wound-care nurse documents stage 4. Which statement is MOST accurate?

  • A. Qualified non-provider documentation may be used to identify the pressure-ulcer stage
  • B. Stage 4 cannot be coded unless the physician documents the stage personally
  • C. The nurse may establish both the pressure-ulcer diagnosis and all associated medical diagnoses
  • D. Pressure-ulcer stage is irrelevant to coding
Reveal Solution  Discussion  0

Correct Answer: A  🗳️

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Under the FY 2026 Hospital Value-Based Purchasing Program, hospital performance is organized into which of the following four domains?

  • A. Patient safety, documentation quality, case mix, and physician engagement
  • B. Mortality, readmissions, reimbursement, and compliance
  • C. Clinical care, claims accuracy, readmissions, and utilization management
  • D. Clinical outcomes, person and community engagement, safety, and efficiency and cost reduction
Reveal Solution  Discussion  0

Correct Answer: D  🗳️

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