ACDIS CCDS Q&A - in .pdf

Exam Code: CCDS
Exam Name: Certified Clinical Documentation Specialist
Updated: Nov 13, 2026
Q & A: 152 Questions and Answers
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Updated: Nov 13, 2026
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Exam Code: CCDS
Exam Name: Certified Clinical Documentation Specialist
Updated: Nov 13, 2026
Q & A: 152 Questions and Answers
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ACDIS CCDS Exam Syllabus Topics:

Section	Weight	Objectives
Professionalism, ethics, and compliance	9.17%	- CDI department goals beyond reimbursement - Compliance risks indicated by PEPPER - Leading queries - Medical record confidentiality - Potential DRG creep - DRG compliance initiatives
Healthcare facility CDI program analysis	8.33%	- PEPPER data - Tracking and trending physician, department, and hospital performance - Case mix index (CMI) - High-frequency DRGs - Severity of illness and risk of mortality - Publicly reported data - Provider response rates - CC/MCC capture - CDI program forecasting - Basic computer and software application skills - Physician performance measurement - Patient Safety Indicators - Hospital-specific financial data - CDI specialist productivity metrics - Hospital Value-Based Purchasing measures
Communication skills	9.17%	- Roles and responsibilities of CDI specialists - Physician education forms and tools - Educational presentations for healthcare departments and administration - Roles and responsibilities of coders working with CDI departments - Reconciling CDI working DRGs with final coded DRGs - Effective and non-confrontational physician communication - Verbal versus written physician communication
Anatomy and physiology, pathophysiology, pharmacology, and medical terminology	19.17%	- Medications as clinical indicators - Diseases and disorders of the nervous system - Endocrine, nutritional, and metabolic diseases and disorders - Standard medical abbreviations - Diagnostic tests as clinical indicators - Infectious and parasitic diseases - Diseases and disorders of the skin, subcutaneous tissue, and breast - Diseases and disorders of the circulatory system - Myeloproliferative diseases and disorders and poorly differentiated neoplasms - Diseases and disorders of the hepatobiliary system - Diseases and disorders of the digestive system - Pharmaceuticals and disease processes - HIV infections - Diseases and disorders of the kidney and urinary tract - Mental diseases and disorders - Clinical indicators and query opportunities by Major Diagnostic Category - Alcohol/drug use and alcohol/drug-induced organic brain disorders - Diseases and disorders of the blood and blood-forming organs and immunological disorders - Injuries, poisonings, and toxic effects of drugs - Diseases and disorders of the respiratory system - Diseases and disorders of the musculoskeletal system
Impact of reportable diagnoses on quality of care	8.33%	- Hospital Value-Based Purchasing - 30-day mortality measures - Mortality reviews and observed/expected ratios - Hospital-Acquired Condition Reduction Program - Hospital Inpatient Quality Reporting Program - Hospital Readmissions Reduction Program - Coded data elements affecting Patient Safety Indicators - Documentation and code assignment impact on mortality index - Healthcare-associated infections and complication codes - Patient Safety Indicators - CDI impact on Hospital Value-Based Purchasing - Quality data from record abstraction and claims data
Medical record documentation	19.17%	- Provider role and diagnosis code assignment - Addressing diagnoses without clinical support - Physician query formats - ACDIS/AHIMA Guidelines for Achieving a Compliant Query Practice - Types of physician queries - Clinical indicators - When a physician query is warranted - Health record elements used for diagnosis and procedure code assignment - Compliant and noncompliant queries - Situations in which queries are not appropriate - Documentation requiring clarification - Translating clinical indicators into compliant queries
Official Guidelines for Coding and Reporting	14.17%	- Working DRG assignment for multiple diagnoses - Coding guidelines for principal diagnosis selection - Hospital-acquired conditions - Secondary diagnosis assignment - Present on admission indicators - Principal diagnosis assignment - AHA Coding Clinic - Official Guidelines for Coding and Reporting updates - Discharge dispositions and transfers
Healthcare regulations, reimbursement, and documentation requirements related to the IPPS	12.5%	- Inpatient admission criteria and CMS Two-Midnight Rule - Case mix index (CMI) - Medicare contractors and their impact on CDI - Documentation impact on IPPS reimbursement - Medical staff and clinical staff documentation responsibilities - Medicare Severity Diagnosis Related Groups (MS-DRGs) - Principal diagnosis and medical necessity - Complication/comorbidity (CC) - IPPS and its updates and revisions - Major complication/comorbidity (MCC) - Documentation and medical necessity of setting - Coding and billing practices vulnerable to denial

ACDIS Certified Clinical Documentation Specialist Sample Questions:

Question #1

A patient is admitted with hypertension and acute systolic heart failure. The provider does not explicitly link the two conditions and does not state that they are unrelated. Which coding principle applies?

A. A relationship may only be recognized when hypertension is the principal diagnosis
B. Hypertension and heart failure must always be coded separately unless the physician states
"hypertensive"
C. Acute heart failure cannot be associated with hypertension
D. ICD-10-CM presumes a relationship between hypertension and qualifying heart disease unless documented as unrelated

Reveal Solution Discussion 0

Correct Answer: D 🗳️