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ACDIS Certified Clinical Documentation Specialist Sample Questions:
Which of the following is considered by CMS to be a HAC requiring MS-DRG adjustment if not POA?
- A. unstageable sacral pressure ulcer
- B. septic shock
- C. DVT following total knee replacement
- D. pneumonia following surgery
Correct Answer: C 🗳️
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A patient has a history of a type 2 MI 30 days ago. The patient is admitted for chest pain which is determined to be an NSTEMI. Which of the following diagnosis(es) should be coded to identify the working MS-DRG?
- A. NSTEMI, subsequent MI, and Type 2 MI
- B. NSTEMI, subsequent MI, chest pain
- C. NSTEMI, initial encounter
- D. NSTEMI and subsequent MI
Correct Answer: C 🗳️
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A patient undergoes total knee replacement. The patient has no DVT on admission but develops a postoperative deep vein thrombosis during the hospitalization. Why is accurate POA documentation particularly important?
- A. Every postoperative DVT automatically eliminates the entire hospital payment
- B. POA status applies only to infectious diseases
- C. A DVT following certain orthopedic procedures can fall within the CMS HAC payment policy
- D. DVTs are never reportable after surgery
Correct Answer: C 🗳️
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A pregnant patient is admitted at 30 weeks' gestation with acute pyelonephritis complicating pregnancy.
Which general sequencing principle applies?
- A. A symptom code must be principal diagnosis
- B. The appropriate Chapter 15 pregnancy complication code generally receives sequencing priority
- C. Pyelonephritis is always sequenced before any obstetric code
- D. Pregnancy is ignored because the infection is unrelated to delivery
Correct Answer: B 🗳️
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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. Clinical care, claims accuracy, readmissions, and utilization management
- C. Mortality, readmissions, reimbursement, and compliance
- D. Clinical outcomes, person and community engagement, safety, and efficiency and cost reduction
Correct Answer: D 🗳️
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