CCDS Exam Mastery: 300 Flashcards
for Clinical Documentation Specialists
1. What is the primary CDI focus in surgical MDCs? - Correct Answer ✔️✔
️Capture of complications and comorbidities.
2. What is one risk if surgical complications are under-documented? - Correct
Answer ✔️✔️Reduced DRG weight and revenue.
3. What documentation supports acute vs. chronic osteomyelitis? - Correct
Answer ✔️✔️Provider must specify acuity (acute or chronic).
4. What is a clinical indicator of acute osteomyelitis? - Correct Answer ✔️✔
️Fever, elevated ESR/CRP, positive bone biopsy.
5. What is a documentation requirement for encephalopathy coding? - Correct
Answer ✔️✔️Type (toxic, metabolic, hepatic, septic, etc.).
6. What is a common CDI target diagnosis in stroke patients? - Correct Answer
✔️✔️Dysphagia.
,7. What test supports dysphagia diagnosis? - Correct Answer ✔️✔️Swallow
evaluation by speech therapy.
8. What documentation must support malnutrition coding? - Correct Answer ✔
️✔️Severity (mild, moderate, or severe).
9. What weight loss percentage suggests severe malnutrition? - Correct Answer
✔️✔️>10% over 6 months.
10. What BMI indicates severe malnutrition? - Correct Answer ✔️✔️<16
kg/m².
11. What is one example of a social determinant of health code? - Correct
Answer ✔️✔️Z59.0 - Homelessness.
12. Why are SDOH codes important? - Correct Answer ✔️✔️They capture
patient risk factors affecting care and outcomes.
13. What is one benefit of CDI reviewing SDOH documentation? - Correct
Answer ✔️✔️Improves holistic patient care representation and risk
adjustment.
,14. What is an example of a vague diagnosis needing clarification? - Correct
Answer ✔️✔️"Renal insufficiency" (should specify acute kidney injury or CKD
stage).
15. What is an example of a compliant POA query? - Correct Answer ✔️✔
️"Was this condition present on admission?"
16. What is one CDI best practice for query follow-up? - Correct Answer ✔️✔
️Track provider response rates and timeliness.
17. What is one example of CDI involvement in readmission reduction? - Correct
Answer ✔️✔️Clarifying comorbidities that affect risk-adjusted readmission
measures.
18. What is the impact of CDI on hospital rankings? - Correct Answer ✔️✔
️Accurate documentation improves publicly reported outcomes.
19. What is one future trend in CDI practice? - Correct Answer ✔️✔
️Expansion into outpatient and risk-adjustment documentation.
, 20. What is the overall mission of CDI professionals? - Correct Answer ✔️✔
️Promote accurate, ethical, and complete clinical documentation to support
patient care and reimbursement.
21. What does CMI stand for? - Correct Answer ✔️✔️Case Mix Index.
22. What does a higher CMI indicate? - Correct Answer ✔️✔️Patients are
more complex and resource-intensive.
23. What is the typical CMI increase from effective CDI programs? - Correct
Answer ✔️✔️0.10-0.25.
24. How much additional revenue can a 0.15 CMI increase generate for a 300-bed
hospital annually? - Correct Answer ✔️✔️About $13.5 million.
25. What are CC and MCC in CDI coding? - Correct Answer ✔️✔
️Complication/Comorbidity and Major Complication/Comorbidity.
26. What is the difference between CC and MCC? - Correct Answer ✔️✔
️MCCs are the most severe, resource-intensive conditions; CCs are moderate
complications.
for Clinical Documentation Specialists
1. What is the primary CDI focus in surgical MDCs? - Correct Answer ✔️✔
️Capture of complications and comorbidities.
2. What is one risk if surgical complications are under-documented? - Correct
Answer ✔️✔️Reduced DRG weight and revenue.
3. What documentation supports acute vs. chronic osteomyelitis? - Correct
Answer ✔️✔️Provider must specify acuity (acute or chronic).
4. What is a clinical indicator of acute osteomyelitis? - Correct Answer ✔️✔
️Fever, elevated ESR/CRP, positive bone biopsy.
5. What is a documentation requirement for encephalopathy coding? - Correct
Answer ✔️✔️Type (toxic, metabolic, hepatic, septic, etc.).
6. What is a common CDI target diagnosis in stroke patients? - Correct Answer
✔️✔️Dysphagia.
,7. What test supports dysphagia diagnosis? - Correct Answer ✔️✔️Swallow
evaluation by speech therapy.
8. What documentation must support malnutrition coding? - Correct Answer ✔
️✔️Severity (mild, moderate, or severe).
9. What weight loss percentage suggests severe malnutrition? - Correct Answer
✔️✔️>10% over 6 months.
10. What BMI indicates severe malnutrition? - Correct Answer ✔️✔️<16
kg/m².
11. What is one example of a social determinant of health code? - Correct
Answer ✔️✔️Z59.0 - Homelessness.
12. Why are SDOH codes important? - Correct Answer ✔️✔️They capture
patient risk factors affecting care and outcomes.
13. What is one benefit of CDI reviewing SDOH documentation? - Correct
Answer ✔️✔️Improves holistic patient care representation and risk
adjustment.
,14. What is an example of a vague diagnosis needing clarification? - Correct
Answer ✔️✔️"Renal insufficiency" (should specify acute kidney injury or CKD
stage).
15. What is an example of a compliant POA query? - Correct Answer ✔️✔
️"Was this condition present on admission?"
16. What is one CDI best practice for query follow-up? - Correct Answer ✔️✔
️Track provider response rates and timeliness.
17. What is one example of CDI involvement in readmission reduction? - Correct
Answer ✔️✔️Clarifying comorbidities that affect risk-adjusted readmission
measures.
18. What is the impact of CDI on hospital rankings? - Correct Answer ✔️✔
️Accurate documentation improves publicly reported outcomes.
19. What is one future trend in CDI practice? - Correct Answer ✔️✔
️Expansion into outpatient and risk-adjustment documentation.
, 20. What is the overall mission of CDI professionals? - Correct Answer ✔️✔
️Promote accurate, ethical, and complete clinical documentation to support
patient care and reimbursement.
21. What does CMI stand for? - Correct Answer ✔️✔️Case Mix Index.
22. What does a higher CMI indicate? - Correct Answer ✔️✔️Patients are
more complex and resource-intensive.
23. What is the typical CMI increase from effective CDI programs? - Correct
Answer ✔️✔️0.10-0.25.
24. How much additional revenue can a 0.15 CMI increase generate for a 300-bed
hospital annually? - Correct Answer ✔️✔️About $13.5 million.
25. What are CC and MCC in CDI coding? - Correct Answer ✔️✔
️Complication/Comorbidity and Major Complication/Comorbidity.
26. What is the difference between CC and MCC? - Correct Answer ✔️✔
️MCCs are the most severe, resource-intensive conditions; CCs are moderate
complications.
