CCDS Practice Exam Questions And
Answers With 100% Verified
Rationales
A concurrent query should aim to clarify:
A. The clinical significance of normal test results
B. Ambiguous, inconsistent, or incomplete documentation
C. The medical treatment plan
D. Which conditions will require outpatient monitoring - ANSWER -B.
Ambiguous, inconsistent, or incomplete documentation
Rationale: Per guidelines, ambiguous documentation fails to reflect the provider's
intent, impacts the clinical scenario (ex. complications, quality of care issues), the
accuracy of code assignment, and the ability to assign a code.
When formulating a credible clinical query, which of the following information
should a CDI specialist incorporate?
A. Last meds take and current meds ordered
B. Risk factors of a condition, s/s of a condition, and treatment
C. D/C plans
D. Possible DRG choices for the physician to review - ANSWER -B. Risk factors
of a condition, s/s of a condition, and treatment
Rationale: Query must meet all criteria: (a) be clear & concise, (b) contain clinical
indicators from health records, (c) present only the facts identifying why
clarification is required, (d) be compliant w/ practices outlined in this brief, (e)
never include impact on reimbursement or quality measures
What is the primary purpose for establishing policies and procedures for creating
concurrent queries?
A. Ensure that retrospective queries do not occur
B. Support achievement on query metrics
,C. Identify when and how to formulate a query
D. Prevent the need for coding audits - ANSWER -C. Identify when and how to
formulate a query
Rationale: The query process should be managed and monitored to ensure it
complies w/ organizational policy.
Metabolic encephalopathy is:
A. Caused by trauma to the head
B. Treated by correcting the underlying condition
C. A minor comorbid condition
D. Usually the Pdx - ANSWER -B. Treated by correcting the underlying condition
Rationale: Treating will vary depending on the identified underlying cause...the
only way to effectively treat encephalopathy is to treat the etiology.
A pt is admitted w/ new-onset severe HA, visual changes, difficulty swallowing
and HTN. Clinically, which dx would best explain these symptoms?
A. Arteriosclerosis
B. Cerebral edema 2nd lesion in brain
C. Acute renal failure
D. ALS - ANSWER -B. Cerebral edema 2nd lesion in brain
Rationale: Symptoms of a brain tumor can be general or specific. A general
symptom is caused by the pressure of the tumor on the brain or spinal cord.
Specific symptoms are caused when a specific part of the brain is not working well
because of the tumor.
An elderly pt w/ h/o COPD and HTN who uses home O2 is admitted w/ c/o
dyspnea, rapid shallow breathing, and O2 sat 84% on 2L O2. A NRB mask is
applied, pt receives IV Solu-Medrol and breathing tx. The physician documents in
notes "respiratory failure d/t COPD vs PNA". What is the most appropriate Pdx?
A. Dyspnea
B. PNA
C. COPD
,D. Resp failure - ANSWER -D. Resp failure
Rationale: Per guidelines, A code from subcategory J96.0, Acute resp failure, or
subcategory J96.2, Acute & chronic respiratory failure, may be assigned as a Pdx
when it is the condition established after study to be chiefly responsible for
occasioning the admission to the hospital. However, chapter specific coding
guidelines (such as OB, poisoning, HIV, newborn) that provide sequencing
direction take precedence.
And elderly pt w/ h/o COPD and HTN who uses home O2 is admitted w/ c/o
dyspnea, rapid shallow breathing and an O2 sat 84% on 2L O2. VS T 99, P 92, R
24, BP 178/92. NRB mask applied, pt receives IV Solu-Medrol and breathing tx.
The physician documents in notes, "acute resp failure d/t COPD vs PNA". What
concurrent query should have been presented to the physician?
A. Whether the physician was treating acute exacerbation of COPD
B. Acuity of resp failure
C. Underlying cause of PNA
D. Whether physician was treating malignant HTN - ANSWER -A. Whether the
physician was treating acute exacerbation of COPD
Rationale: Decompensated resp function as compared to the pt's baseline (already
on home O2) indicates an acute exacerbation of the pt's baseline chronic condition.
A pt is being treated w/ cefoxitin for PNA. What type of PNA is most likely being
treated?
A. Bacterial
B. Fungal
C. Aspiration
D. Parasitic - ANSWER -A. Bacterial
Rationale: Cefoxitin is a semi-synthetic, broad-spectrum cepha abx for IV admin,
commonly used in bacterial infections.
, A patient is admitted w/ fever, shortness of breath, chest pain, and non-productive
cough. CXR confirms pleural effusion. Which type of effusion is most probable for
this pt?
A. Malignant
B. Transudative
C. Exudative
D. Serosanguinous - ANSWER -C. Exudative
Rationale: Transudative pleural effusion is caused by fluid leaking into the pleural
space. This is from increased pressure in the blood vessels or a low blood protein
count. Heart failure is the most common cause. Exudative effusion is caused by
blocked blood vessels or lymph vessels, inflammation, infection, lung injury, and
tumors.
Clinical indicators of acute resp failure most commonly include:
A. Use of accessory muscle and ability to speak more than a few words at time
B. Hyper-resonant lung sounds
C. O2 sat 95% on 2L O2
D. Bradycardia - ANSWER -A. Use of accessory muscle and ability to speak more
than a few words at time
Rationale: Pt w/ acute resp failure usually presents w/ evidence of increased work
of breathing. Typical s/s include rapid RR, use of accessory respiration muscle (ex.
intercostal muscle retraction, paradoxical breathing) and cyanosis.
An elderly pt w/ h/o CAD, GERD, HTN is admitted w/ chest pain. The pain was
unrelieved w/ NTG at home. A GI cocktail is administered in ED w/ relief. Cardiac
workup is neg., and pt is scheduled for an EGD. The physician documents atypical
chest pain. Does this scenario call for a concurrent query?
A. No, GERD can be coded as Pdx
B. Yes, to specify cause of chest pain
C. No, because chest pain is the Pdx
D. yes, to specify type of GERD - ANSWER -B. Yes, to specify cause of chest
pain
Answers With 100% Verified
Rationales
A concurrent query should aim to clarify:
A. The clinical significance of normal test results
B. Ambiguous, inconsistent, or incomplete documentation
C. The medical treatment plan
D. Which conditions will require outpatient monitoring - ANSWER -B.
Ambiguous, inconsistent, or incomplete documentation
Rationale: Per guidelines, ambiguous documentation fails to reflect the provider's
intent, impacts the clinical scenario (ex. complications, quality of care issues), the
accuracy of code assignment, and the ability to assign a code.
When formulating a credible clinical query, which of the following information
should a CDI specialist incorporate?
A. Last meds take and current meds ordered
B. Risk factors of a condition, s/s of a condition, and treatment
C. D/C plans
D. Possible DRG choices for the physician to review - ANSWER -B. Risk factors
of a condition, s/s of a condition, and treatment
Rationale: Query must meet all criteria: (a) be clear & concise, (b) contain clinical
indicators from health records, (c) present only the facts identifying why
clarification is required, (d) be compliant w/ practices outlined in this brief, (e)
never include impact on reimbursement or quality measures
What is the primary purpose for establishing policies and procedures for creating
concurrent queries?
A. Ensure that retrospective queries do not occur
B. Support achievement on query metrics
,C. Identify when and how to formulate a query
D. Prevent the need for coding audits - ANSWER -C. Identify when and how to
formulate a query
Rationale: The query process should be managed and monitored to ensure it
complies w/ organizational policy.
Metabolic encephalopathy is:
A. Caused by trauma to the head
B. Treated by correcting the underlying condition
C. A minor comorbid condition
D. Usually the Pdx - ANSWER -B. Treated by correcting the underlying condition
Rationale: Treating will vary depending on the identified underlying cause...the
only way to effectively treat encephalopathy is to treat the etiology.
A pt is admitted w/ new-onset severe HA, visual changes, difficulty swallowing
and HTN. Clinically, which dx would best explain these symptoms?
A. Arteriosclerosis
B. Cerebral edema 2nd lesion in brain
C. Acute renal failure
D. ALS - ANSWER -B. Cerebral edema 2nd lesion in brain
Rationale: Symptoms of a brain tumor can be general or specific. A general
symptom is caused by the pressure of the tumor on the brain or spinal cord.
Specific symptoms are caused when a specific part of the brain is not working well
because of the tumor.
An elderly pt w/ h/o COPD and HTN who uses home O2 is admitted w/ c/o
dyspnea, rapid shallow breathing, and O2 sat 84% on 2L O2. A NRB mask is
applied, pt receives IV Solu-Medrol and breathing tx. The physician documents in
notes "respiratory failure d/t COPD vs PNA". What is the most appropriate Pdx?
A. Dyspnea
B. PNA
C. COPD
,D. Resp failure - ANSWER -D. Resp failure
Rationale: Per guidelines, A code from subcategory J96.0, Acute resp failure, or
subcategory J96.2, Acute & chronic respiratory failure, may be assigned as a Pdx
when it is the condition established after study to be chiefly responsible for
occasioning the admission to the hospital. However, chapter specific coding
guidelines (such as OB, poisoning, HIV, newborn) that provide sequencing
direction take precedence.
And elderly pt w/ h/o COPD and HTN who uses home O2 is admitted w/ c/o
dyspnea, rapid shallow breathing and an O2 sat 84% on 2L O2. VS T 99, P 92, R
24, BP 178/92. NRB mask applied, pt receives IV Solu-Medrol and breathing tx.
The physician documents in notes, "acute resp failure d/t COPD vs PNA". What
concurrent query should have been presented to the physician?
A. Whether the physician was treating acute exacerbation of COPD
B. Acuity of resp failure
C. Underlying cause of PNA
D. Whether physician was treating malignant HTN - ANSWER -A. Whether the
physician was treating acute exacerbation of COPD
Rationale: Decompensated resp function as compared to the pt's baseline (already
on home O2) indicates an acute exacerbation of the pt's baseline chronic condition.
A pt is being treated w/ cefoxitin for PNA. What type of PNA is most likely being
treated?
A. Bacterial
B. Fungal
C. Aspiration
D. Parasitic - ANSWER -A. Bacterial
Rationale: Cefoxitin is a semi-synthetic, broad-spectrum cepha abx for IV admin,
commonly used in bacterial infections.
, A patient is admitted w/ fever, shortness of breath, chest pain, and non-productive
cough. CXR confirms pleural effusion. Which type of effusion is most probable for
this pt?
A. Malignant
B. Transudative
C. Exudative
D. Serosanguinous - ANSWER -C. Exudative
Rationale: Transudative pleural effusion is caused by fluid leaking into the pleural
space. This is from increased pressure in the blood vessels or a low blood protein
count. Heart failure is the most common cause. Exudative effusion is caused by
blocked blood vessels or lymph vessels, inflammation, infection, lung injury, and
tumors.
Clinical indicators of acute resp failure most commonly include:
A. Use of accessory muscle and ability to speak more than a few words at time
B. Hyper-resonant lung sounds
C. O2 sat 95% on 2L O2
D. Bradycardia - ANSWER -A. Use of accessory muscle and ability to speak more
than a few words at time
Rationale: Pt w/ acute resp failure usually presents w/ evidence of increased work
of breathing. Typical s/s include rapid RR, use of accessory respiration muscle (ex.
intercostal muscle retraction, paradoxical breathing) and cyanosis.
An elderly pt w/ h/o CAD, GERD, HTN is admitted w/ chest pain. The pain was
unrelieved w/ NTG at home. A GI cocktail is administered in ED w/ relief. Cardiac
workup is neg., and pt is scheduled for an EGD. The physician documents atypical
chest pain. Does this scenario call for a concurrent query?
A. No, GERD can be coded as Pdx
B. Yes, to specify cause of chest pain
C. No, because chest pain is the Pdx
D. yes, to specify type of GERD - ANSWER -B. Yes, to specify cause of chest
pain
