CCDS Exam Cram Review | CCDS Exam Sample Questions

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ACDIS CCDS Exam Syllabus Topics:

Section	Weight	Objectives
Topic 1: Quality, Risk Adjustment & Health Initiatives	15%	- Severity of Illness (SOI) / Risk of Mortality (ROM) - Risk adjustment models and documentation impact - Quality reporting, public reporting, and compliance programs
Topic 2: Clinical Documentation Review & Query Practices	20%	- Documentation gap identification and resolution - Concurrent and retrospective chart review methodologies - Query development, communication, and ethical standards
Topic 3: Coding Guidelines & Official Reporting Standards	15%	- ICD-10-CM/PCS Official Guidelines for Coding and Reporting - Coding integrity and compliant documentation practices - AHIMA/ACDIS Guidelines for Compliant Query Practice
Topic 4: Clinical Knowledge & Disease Processes Application	20%	- Disease processes across body systems applied to chart review - Clinical indicators, lab results, medications, diagnostic findings - Medical terminology, anatomy, physiology, pathophysiology
Topic 5: CDI Program Management & Professional Practice	15%	- Program metrics, benchmarks, and performance measurement - Ethics, HIPAA, and professional conduct - Provider education and training strategies
Topic 6: Healthcare Regulations, Reimbursement & Documentation Requirements – IPPS	15%	- Medicare Severity Diagnostic Related Groups (MS-DRGs) - Documentation responsibilities of medical and clinical staff - Inpatient Prospective Payment System (IPPS) fundamentals

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ACDIS CCDS Questions Can Help you Pass Exam [2026]

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ACDIS Certified Clinical Documentation Specialist Sample Questions (Q106-Q111):

NEW QUESTION # 106
During one month, a CDI department issued 400 queries. Providers responded to 360 of them. What was the provider query response rate?

A. 10%
B. 90%
C. 40%
D. 111%

Answer: B

Explanation:
Provider query response rate is calculated by dividing the number of answered queries by the total number of queries requiring a response, then multiplying by 100.
360 ÷ 400 × 100 = 90%.
Therefore, the provider response rate is 90%.
Response rate measures whether clinicians engage with documentation clarification requests. It should be distinguished from agreement rate, which measures how often the provider's response supports the diagnosis or clarification being considered. A physician can respond appropriately while disagreeing with the proposed diagnostic possibilities, so a lower agreement rate does not necessarily indicate poor engagement.
A CDI manager should also evaluate response timeliness, service-line patterns, unanswered-query aging, escalation frequency, and whether responses result in complete documentation.
A response rate should not be artificially increased by pressuring providers to choose a particular answer.
Current ACDIS/AHIMA guidance emphasizes a compliant clarification process that preserves independent provider judgment.
In mature CDI programs, metrics are best evaluated longitudinally rather than in isolation. Significant changes should be examined for workflow, staffing, education, electronic-query functionality, or physician- engagement factors.
CCDS Reference Topics: Query response rate; CDI metrics; provider engagement; program analysis; communication.
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NEW QUESTION # 107
A patient is admitted with community-acquired pneumonia. On day 3, he begins to show signs of increasing respiratory distress and requires intubation. When he arrives in the ICU, the nurse inserts a urinary catheter and notes that his urine output has decreased. The physician documents respiratory failure and acute renal failure secondary to sepsis caused by pneumonia. The patient's condition would be classified as:

A. septic shock
B. septicemia
C. severe sepsis
D. sepsis

Answer: C

Explanation:
This patient has sepsis with documented acute organ dysfunction, specifically acute respiratory failure and acute renal failure. Under ICD-10-CM coding guidance, sepsis associated with acute organ dysfunction is classified as severe sepsis when the provider establishes the relationship between the systemic infection and the organ dysfunction.
The documentation specifically states that respiratory failure and acute renal failure are secondary to sepsis caused by pneumonia. That causal linkage is critical. FY 2026 Official Guidelines require the underlying systemic infection code, followed by a code from R65.2- for severe sepsis, plus additional codes identifying each associated acute organ dysfunction.
Septic shock is not supported because the scenario does not document circulatory failure attributable to sepsis, persistent hypotension requiring vasopressors, or a provider diagnosis of septic shock. "Septicemia" is also not equivalent terminology for coding sepsis and is not the appropriate classification here.
From a CDI perspective, the defining feature is not simply that the patient is critically ill. It is the documented relationship between sepsis and acute organ dysfunction.
CCDS Reference Topics: Sepsis; severe sepsis; acute organ dysfunction; sequencing guidelines.
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NEW QUESTION # 108
The MOST important factor influencing a hospital's ability to capture the most accurate MS-DRG involves:

A. Capture of patient satisfaction indicators
B. Complete clinical documentation
C. Complete POA documentation
D. Capture of clinical quality indicators

Answer: B

Explanation:
Complete clinical documentation is the foundation of accurate MS-DRG assignment. The coding process translates provider documentation into ICD-10-CM and ICD-10-PCS codes, and those codes drive the MS- DRG grouper. If the record does not accurately capture the principal diagnosis, secondary diagnoses, acuity, etiologies, complications, procedures, and clinically relevant relationships, the resulting MS-DRG may not accurately represent the patient's hospitalization.
CMS explains that MS-DRG assignment depends on factors including diagnoses, procedures, complicating conditions, age, sex, and discharge status. Each resulting MS-DRG has a payment weight representing relative resource requirements.
POA documentation is important, particularly for HAC payment logic, but it is only one component of overall documentation completeness. Quality indicators and patient-satisfaction information serve other important organizational purposes but do not substitute for complete provider documentation when grouping the inpatient claim.
The role of CDI is therefore broader than capturing CCs or MCCs. CDI professionals work to ensure that the entire medical record provides a precise clinical description of the patient and services rendered, allowing coding, quality reporting, risk adjustment, utilization review, and reimbursement to be based on the same accurate clinical story.
CCDS Reference Topics: Documentation integrity; MS-DRG assignment; principal/secondary diagnoses; CDI fundamentals.
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NEW QUESTION # 109
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 outcomes, person and community engagement, safety, and efficiency and cost reduction
C. Clinical care, claims accuracy, readmissions, and utilization management
D. Mortality, readmissions, reimbursement, and compliance

Answer: B

Explanation:
For FY 2026, CMS Hospital Value-Based Purchasing performance is organized into four domains: Clinical Outcomes; Person and Community Engagement; Safety; and Efficiency and Cost Reduction. CMS reports that each domain contributes to the hospital's Total Performance Score, with the FY 2026 dataset showing weighted scores for all four domains.
The Hospital VBP Program is funded by reducing participating hospitals' base operating DRG payments by
2% and redistributing the amount through value-based incentive payments according to program performance.
CDI professionals are particularly relevant to quality reporting because complete and accurate documentation can influence coded clinical information used in mortality, complications, risk adjustment, patient-safety analysis, and other quality processes. Documentation integrity should not be manipulated to improve scores; rather, the health record must accurately reflect the patient's actual severity and clinical course.
ACDIS explicitly includes Hospital VBP measures, SOI/ROM, Patient Safety Indicators, and publicly reported quality data within CCDS program-analysis competencies.
CCDS Reference Topics: Hospital VBP; quality reporting; Safety domain; Clinical Outcomes; CDI impact on publicly reported data.
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NEW QUESTION # 110
The physician evaluates a postoperative wound infection but states, "I cannot clinically determine whether the infection was already developing at admission or began after admission." Which POA indicator MOST accurately reflects this provider determination?

A. W
B. N
C. U
D. Y

Answer: A

Explanation:
POA indicator W means the provider is clinically unable to determine whether the condition was present on admission. That is precisely what is documented in this scenario.
This must be distinguished from POA indicator U. U means the documentation is insufficient to determine POA status, whereas W reflects an actual clinical determination that the timing cannot be established even after appropriate assessment.
Indicator Y means the condition was present when the inpatient admission order occurred, while N means it was not present at that point.
This distinction matters because POA status contributes to CMS Hospital-Acquired Condition payment logic and hospital quality analyses. CDI specialists should attempt to obtain clarification when timing is unclear, but they must accept a legitimate provider determination that onset cannot clinically be established.
Not every ambiguous timeline should be forced into either Y or N. When clinical evidence truly cannot resolve the timing, W is an appropriate reporting outcome.
CMS maintains separate annual POA-exempt resources and HAC/POA coding information for the applicable fiscal year.
CCDS Reference Topics: POA indicators; W versus U; onset timing; HACs; inpatient coding.
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NEW QUESTION # 111
......

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