CCDS Exam (Certified Clinical
Documentation Specialist) EXAM
LATEST VERSION QUESTIONS AND
VERIFIED CORRECT ANSWERS JUST
RELEASED .pdf
Question 1: A CDI specialist is reviewing a patient's chart and notices that the physician
documented "CHF" in the progress notes but the patient has a history of both systolic and
diastolic heart failure. Which action should the CDI specialist take?
A) Query the physician for clarification of the type of heart failure
B) Assign the code for CHF unspecified
C) Ignore the documentation as it is sufficient for coding
D) Ask the nurse to clarify the diagnosis
Page 1
,Correct Answer: A
Querying for clarification of the type of heart failure is appropriate because "CHF" is a
nonspecific term that fails to capture the severity and type of heart failure, which impacts
DRG assignment and severity of illness. The CDI specialist should query for specificity
when documentation is ambiguous or incomplete .
Question 2: A patient is admitted with respiratory failure due to COPD versus pneumonia.
The physician documents "respiratory failure due to COPD vs PNA" in the progress notes.
What is the most appropriate principal diagnosis?
A) Dyspnea
B) Pneumonia
C) COPD
D) Respiratory failure
Correct Answer: D
When the documentation is unclear as to whether acute respiratory failure and another
condition are equally responsible for occasioning the admission, the condition that
necessitated the admission and was the primary focus of treatment should be sequenced
as principal. In this case, the respiratory failure is the focus of treatment with oxygen and
medications .
Question 3: Which of the following is the gold standard resource for obtaining official
coding advice and clarifications on ICD-10-CM/PCS guidelines?
A) Medicare Administrative Contractor bulletins
B) The AHA Coding Clinic for ICD-10-CM/PCS
C) Commercial coding textbooks
D) Internal hospital policy manuals
Page 2
, Correct Answer: B
Coding Clinic, published quarterly by the American Hospital Association in cooperation
with CMS and NCHS, is the official and authoritative source for advice on ICD-10 coding
and reporting requirements. Its guidance is binding for correct coding .
Question 4: What does a hospital's Case Mix Index (CMI) quantitatively represent?
A) The average number of diagnoses per patient discharge
B) The average relative weight of all MS-DRGs billed in a given period, reflecting average
patient complexity and resource intensity
C) The ratio of medical to surgical discharges
D) The total Medicare reimbursement received in a fiscal year
Correct Answer: B
CMI is the average DRG relative weight for a hospital or patient population. A higher CMI
indicates a mix of patients with greater severity and/or more resource-intensive conditions.
It is a key financial metric directly tied to reimbursement under IPPS .
Question 5: A CDI specialist notes that a principal diagnosis of "Acute Hypoxemic
Respiratory Failure" yields a higher-weighted DRG than "Acute Respiratory Failure." What
should the CDI specialist do?
A) Query the physician for specificity of the type of respiratory failure
B) Assign the higher-weighted DRG without querying
C) Code both diagnoses
D) Ignore the difference as it does not affect reimbursement
Correct Answer: A
Page 3
Documentation Specialist) EXAM
LATEST VERSION QUESTIONS AND
VERIFIED CORRECT ANSWERS JUST
RELEASED .pdf
Question 1: A CDI specialist is reviewing a patient's chart and notices that the physician
documented "CHF" in the progress notes but the patient has a history of both systolic and
diastolic heart failure. Which action should the CDI specialist take?
A) Query the physician for clarification of the type of heart failure
B) Assign the code for CHF unspecified
C) Ignore the documentation as it is sufficient for coding
D) Ask the nurse to clarify the diagnosis
Page 1
,Correct Answer: A
Querying for clarification of the type of heart failure is appropriate because "CHF" is a
nonspecific term that fails to capture the severity and type of heart failure, which impacts
DRG assignment and severity of illness. The CDI specialist should query for specificity
when documentation is ambiguous or incomplete .
Question 2: A patient is admitted with respiratory failure due to COPD versus pneumonia.
The physician documents "respiratory failure due to COPD vs PNA" in the progress notes.
What is the most appropriate principal diagnosis?
A) Dyspnea
B) Pneumonia
C) COPD
D) Respiratory failure
Correct Answer: D
When the documentation is unclear as to whether acute respiratory failure and another
condition are equally responsible for occasioning the admission, the condition that
necessitated the admission and was the primary focus of treatment should be sequenced
as principal. In this case, the respiratory failure is the focus of treatment with oxygen and
medications .
Question 3: Which of the following is the gold standard resource for obtaining official
coding advice and clarifications on ICD-10-CM/PCS guidelines?
A) Medicare Administrative Contractor bulletins
B) The AHA Coding Clinic for ICD-10-CM/PCS
C) Commercial coding textbooks
D) Internal hospital policy manuals
Page 2
, Correct Answer: B
Coding Clinic, published quarterly by the American Hospital Association in cooperation
with CMS and NCHS, is the official and authoritative source for advice on ICD-10 coding
and reporting requirements. Its guidance is binding for correct coding .
Question 4: What does a hospital's Case Mix Index (CMI) quantitatively represent?
A) The average number of diagnoses per patient discharge
B) The average relative weight of all MS-DRGs billed in a given period, reflecting average
patient complexity and resource intensity
C) The ratio of medical to surgical discharges
D) The total Medicare reimbursement received in a fiscal year
Correct Answer: B
CMI is the average DRG relative weight for a hospital or patient population. A higher CMI
indicates a mix of patients with greater severity and/or more resource-intensive conditions.
It is a key financial metric directly tied to reimbursement under IPPS .
Question 5: A CDI specialist notes that a principal diagnosis of "Acute Hypoxemic
Respiratory Failure" yields a higher-weighted DRG than "Acute Respiratory Failure." What
should the CDI specialist do?
A) Query the physician for specificity of the type of respiratory failure
B) Assign the higher-weighted DRG without querying
C) Code both diagnoses
D) Ignore the difference as it does not affect reimbursement
Correct Answer: A
Page 3
