Certified Clinical Documentation Specialist: CCDS Exam

"Certified Clinical Documentation Specialist", also known as CCDS exam, is a ACDIS Certification. With the complete collection of questions and answers, iPassleader has assembled to take you through 152 Q&As to your CCDS Exam preparation. In the CCDS exam resources, you will cover every field and category in Clinical Documentation Specialist Certification helping to ready you for your successful ACDIS Certification.

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  • Updated on: Sep 28, 2026
  • No. of Questions: 152 Questions & Answers

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  • Updated on: Sep 28, 2026
  • No. of Questions: 152 Questions & Answers

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ACDIS Certified Clinical Documentation Specialist Sample Questions:

A patient was admitted with weakness, loss of appetite, hemoglobin 7.8, WBC 2,700, and platelet count 58.
The admitting diagnoses on the history and physical were anemia, leukopenia, decreased platelets, and rule out myelodysplastic syndrome. Based on these clinical indicators a CDI specialist should query for which of the following conditions?

  • A. thrombocytopenia
  • B. pancytopenia
  • C. myelophthisis
  • D. aplastic anemia
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Correct Answer: B  🗳️

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A CDI specialist identifies fever, leukocytosis, tachycardia, positive blood cultures, and IV antibiotic treatment. No infectious diagnosis has been documented. Which query approach is MOST compliant?

  • A. Wait until discharge and automatically code sepsis if antibiotics are continued
  • B. "Can you confirm that the patient has sepsis? Yes or No."
  • C. "Please document sepsis because the patient meets sepsis criteria."
  • D. Present the relevant clinical indicators and offer clinically reasonable diagnostic choices, including an alternative response
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Correct Answer: D  🗳️

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A patient is admitted with TIA, right-sided weakness, and slurred speech. The physician's physical examination notes that the patient's right-sided weakness continues, but the slurred speech has resolved. A CT scan of the brain reveals a new hypodense area. The most specific diagnosis to query is acute:

  • A. Transient cerebral ischemia
  • B. Encephalopathy
  • C. Transient global amnesia
  • D. Cerebral infarction
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Correct Answer: D  🗳️

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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. Acute heart failure cannot be associated with hypertension
  • C. Hypertension and heart failure must always be coded separately unless the physician states
    "hypertensive"
  • D. ICD-10-CM presumes a relationship between hypertension and qualifying heart disease unless documented as unrelated
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Correct Answer: D  🗳️

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A hospital had 1,000 inpatient discharges during a reporting period. The sum of the MS-DRG relative weights for those discharges was 1,750. What is the hospital's case mix index (CMI)?

  • A. 0.57
  • B. 2.75
  • C. 1.75
  • D. 1.00
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Correct Answer: C  🗳️

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