CCDS Exam (Certified Clinical Documentation Specialist) EXAM
2026-2027 LATEST VERSION QUESTIONS AND VERIFIED
CORRECT ANSWERS JUST RELEASED
A patient being treated with cefoxitin for pneumonia. What type of pneumonia is
most likely being treated?
A. Gram positive
B. Community acquired
C. Gram negative
D. Pneumococcal - answer>>>C. Gram negative
A patient is admitted with fever, shortness of breath, chest pain, and non-
productive cough. Chest x-ray confirms a pleural effusion. Which type of effusion is
most probable for this patient?
A. Malignant
B. Transudative
C. Exudative
D. Serosanguinous - answer>>>C. Exudative
Clinical indicators of acute respiratory failure most commonly include:
1. Use of accessory muscles
2. Work of breathing
3. Inability to speak more than a few words at a time
4. Oxygen saturations below 95% on 2L oxygen
5. Tachycardia
A. 1,2, and 3
B. 2,3, and 5
, -
C. 3,4, and 5
D. 1,3, and 5 - answer>>>A. 1,2, and 3
1. Use of accessory muscles
2. Work of breathing
3. Inability to speak more than a few words at a time
An elderly patient with a history of CAD, GERD, and HTN is admitted with chest pain.
Pain was unrelieved with nitroglycerin at home. A GI cocktail is administered in the
ED with relief. Cardiac workup is negative, and patient is scheduled for an EGD. The
physician documents atypical chest pain. A concurrent query:
A. Is not necessary to code GERD as the principal diagnosis
B. Would be needed to specify the cause of the chest pain
C. Would not be necessary as chest pain is the principal diagnosis
D. Would be needed to specify the type of GERD - answer>>>B. Would be needed to
specify the cause of the chest pain
A patient is admitted with syncope. Typical considerations for the underlying cause
of syncope include:
A. Cardiac arrhythmia and fluid overload
B. CHF and renal failure
C. Diabetes, bradycardia, and dehydration
D. Obesity and colon cancer - answer>>>C. Diabetes, bradycardia, and dehydration
When a patient's admission includes a reimbursable surgical procedure, assignment
of the final MS-DRG will:
,A. Always be in the same MDC as the principal medical diagnosis
B. Always include a comorbid condition (CC/MCC)
C. Depend on the patient's age
D. Be driven by the surgical hierarchy established by CMS - answer>>>D. Be driven
by the surgical hierarchy established by CMS
When concurrently formulating a query to clarify whether a patient has a
gastrointestinal hemorrhage, it is important to assist the physician in understanding
which of the following coding rules?
A. Active bleeding does not need to be visualized in an endoscopy; the physician
impression can be documented and coded
B. Bleeding must be visualized in order to code an active bleed
C. A positive hemoccult is sufficient documentation to code GI hemorrhage
D. The EGD report will be used to code the location of the GI hemorrhage -
answer>>>A. Active bleeding does not need to be visualized in an endoscopy; the
physician impression can be documented and coded
A patient is admitted with cholelithiasis and is scheduled for a laparoscopic
cholecystectomy. When reviewing the operation report, the documentation
specialist notes the words "dilation of the sphincter of Oddi." This is important
because it indicates:
A. Stones may have been left behind
B. A non-reimbursable procedure was performed
C. The procedure had to be performed via an incision and will lead to a different
surgical MS-DRG
D. A complication that will code as an MCC - answer>>>C. The procedure had to be
performed via an incision and will lead to a different surgical MS-DRG
, -
It is important to clarify the type of debridement that is performed during a
patient's hospital stay because debridement:
A. Is not reimbursable if performed by wound care nurses
B. Should be identified by the type of debridement and the depth of tissue removed
C. Is a hospital-acquired condition that does not provide reimbursement
D. Is not reimbursable if performed at the bedside - answer>>>B. Should be
identified by the type of debridement and the depth of tissue removed
Which of the following would be an important indicator of severe malnutrition?
A. Albumin of 2.9
B. Poor or delaying wound healing
C. Patient is 90% of ideal body weight
D. Patient is NPO after midnight for surgery scheduled the next day - answer>>>B.
Poor or delaying wound healing
A patient is admitted with weakness, dehydration, and AMS. The patient also has a
history of CKD stage 2 with a baseline creatinine of 1.6, CHF, HTN, and CABG. Blood
urea nitrogen (BUN) is 32, creatinine is 2.4, and urine analysis is positive for white
blood cells. Head CT is negative for acute changes. The patient is started on IV fluids
and antibiotics. Labs after 2 liters of fluid are BUN 28 and creatinine 1.7. The
physician documents the following impression list:
-Dehydration with pre-renal azotemia
-UTI
-CKD
-AMS
2026-2027 LATEST VERSION QUESTIONS AND VERIFIED
CORRECT ANSWERS JUST RELEASED
A patient being treated with cefoxitin for pneumonia. What type of pneumonia is
most likely being treated?
A. Gram positive
B. Community acquired
C. Gram negative
D. Pneumococcal - answer>>>C. Gram negative
A patient is admitted with fever, shortness of breath, chest pain, and non-
productive cough. Chest x-ray confirms a pleural effusion. Which type of effusion is
most probable for this patient?
A. Malignant
B. Transudative
C. Exudative
D. Serosanguinous - answer>>>C. Exudative
Clinical indicators of acute respiratory failure most commonly include:
1. Use of accessory muscles
2. Work of breathing
3. Inability to speak more than a few words at a time
4. Oxygen saturations below 95% on 2L oxygen
5. Tachycardia
A. 1,2, and 3
B. 2,3, and 5
, -
C. 3,4, and 5
D. 1,3, and 5 - answer>>>A. 1,2, and 3
1. Use of accessory muscles
2. Work of breathing
3. Inability to speak more than a few words at a time
An elderly patient with a history of CAD, GERD, and HTN is admitted with chest pain.
Pain was unrelieved with nitroglycerin at home. A GI cocktail is administered in the
ED with relief. Cardiac workup is negative, and patient is scheduled for an EGD. The
physician documents atypical chest pain. A concurrent query:
A. Is not necessary to code GERD as the principal diagnosis
B. Would be needed to specify the cause of the chest pain
C. Would not be necessary as chest pain is the principal diagnosis
D. Would be needed to specify the type of GERD - answer>>>B. Would be needed to
specify the cause of the chest pain
A patient is admitted with syncope. Typical considerations for the underlying cause
of syncope include:
A. Cardiac arrhythmia and fluid overload
B. CHF and renal failure
C. Diabetes, bradycardia, and dehydration
D. Obesity and colon cancer - answer>>>C. Diabetes, bradycardia, and dehydration
When a patient's admission includes a reimbursable surgical procedure, assignment
of the final MS-DRG will:
,A. Always be in the same MDC as the principal medical diagnosis
B. Always include a comorbid condition (CC/MCC)
C. Depend on the patient's age
D. Be driven by the surgical hierarchy established by CMS - answer>>>D. Be driven
by the surgical hierarchy established by CMS
When concurrently formulating a query to clarify whether a patient has a
gastrointestinal hemorrhage, it is important to assist the physician in understanding
which of the following coding rules?
A. Active bleeding does not need to be visualized in an endoscopy; the physician
impression can be documented and coded
B. Bleeding must be visualized in order to code an active bleed
C. A positive hemoccult is sufficient documentation to code GI hemorrhage
D. The EGD report will be used to code the location of the GI hemorrhage -
answer>>>A. Active bleeding does not need to be visualized in an endoscopy; the
physician impression can be documented and coded
A patient is admitted with cholelithiasis and is scheduled for a laparoscopic
cholecystectomy. When reviewing the operation report, the documentation
specialist notes the words "dilation of the sphincter of Oddi." This is important
because it indicates:
A. Stones may have been left behind
B. A non-reimbursable procedure was performed
C. The procedure had to be performed via an incision and will lead to a different
surgical MS-DRG
D. A complication that will code as an MCC - answer>>>C. The procedure had to be
performed via an incision and will lead to a different surgical MS-DRG
, -
It is important to clarify the type of debridement that is performed during a
patient's hospital stay because debridement:
A. Is not reimbursable if performed by wound care nurses
B. Should be identified by the type of debridement and the depth of tissue removed
C. Is a hospital-acquired condition that does not provide reimbursement
D. Is not reimbursable if performed at the bedside - answer>>>B. Should be
identified by the type of debridement and the depth of tissue removed
Which of the following would be an important indicator of severe malnutrition?
A. Albumin of 2.9
B. Poor or delaying wound healing
C. Patient is 90% of ideal body weight
D. Patient is NPO after midnight for surgery scheduled the next day - answer>>>B.
Poor or delaying wound healing
A patient is admitted with weakness, dehydration, and AMS. The patient also has a
history of CKD stage 2 with a baseline creatinine of 1.6, CHF, HTN, and CABG. Blood
urea nitrogen (BUN) is 32, creatinine is 2.4, and urine analysis is positive for white
blood cells. Head CT is negative for acute changes. The patient is started on IV fluids
and antibiotics. Labs after 2 liters of fluid are BUN 28 and creatinine 1.7. The
physician documents the following impression list:
-Dehydration with pre-renal azotemia
-UTI
-CKD
-AMS
