Exam Name: Certified Clinical Documentation Specialist
Certification Provider: ACDIS
Corresponding Certification: Clinical Documentation Specialist
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ACDIS CCDS Exam Syllabus Topics:
| Section | Weight | Objectives |
|---|---|---|
| Topic 1: Medical record documentation | 19.17% | - Documentation clarification and compliant physician queries - Documentation requirements and diagnosis or procedure code assignment |
| Topic 2: Communication skills | 9.17% | - Physician education and effective communication - CDI and coding roles and interdisciplinary collaboration |
| Topic 3: Healthcare facility CDI program analysis | 8.33% | - CDI productivity, provider response, CMI, and program metrics - Data analysis, forecasting, and performance measurement |
| Topic 4: Impact of reportable diagnoses on quality of care | 8.33% | - Quality metrics, reporting programs, and financial impact - Mortality, severity of illness, and risk of mortality |
| Topic 5: Official Guidelines for Coding and Reporting | 14.17% | - Principal and secondary diagnosis assignment - Coding guidelines, AHA Coding Clinic, HACs, and POA indicators |
| Topic 6: Healthcare regulations, reimbursement, and documentation requirements related to the IPPS | 12.5% | - CC/MCC, CMI, Medicare contractors, and compliance - IPPS, MS-DRGs, reimbursement, and medical necessity |
| Topic 7: Anatomy and physiology, pathophysiology, pharmacology, and medical terminology | 19.17% | - Clinical conditions and clinical indicators - Anatomy, physiology, pathophysiology, pharmacology, and terminology |
| Topic 8: Professionalism, ethics, and compliance | 9.17% | - Query compliance, DRG creep, and audit risks - Confidentiality, DRG compliance, and ethical CDI practices |
ACDIS Certified Clinical Documentation Specialist Sample Questions:
Which statement BEST describes the basic funding mechanism of the Hospital Value-Based Purchasing Program?
- A. Only hospitals with HACs contribute to the program
- B. The program is budget neutral and uses a 2% reduction in base operating DRG payments to fund value- based incentive payments
- C. CMS permanently removes 5% of all MS-DRG payments from participating hospitals
- D. The program adjusts only professional physician payments
Correct Answer: B 🗳️
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The attending physician documents morbid obesity. A registered dietitian documents a body mass index of
43.6 kg/m² in the nutritional assessment. Which of the following is the MOST accurate statement?
- A. The BMI cannot be coded because it was not documented by the physician
- B. The dietitian's BMI documentation can also establish the diagnosis of morbid obesity
- C. Neither obesity nor BMI can be reported unless both appear in the discharge summary
- D. The BMI may be obtained from the dietitian's documentation because the associated diagnosis is documented by the provider
Correct Answer: D 🗳️
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A patient with colon cancer is admitted solely for transfusion and management of anemia caused directly by the malignancy. No chemotherapy-related adverse effect is involved. Which condition is sequenced first?
- A. Colon malignancy
- B. Encounter for transfusion
- C. Anemia in neoplastic disease
- D. Weakness
Correct Answer: A 🗳️
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Which of the following programs specifically reduces applicable Medicare payments by 1% for hospitals in the worst-performing quartile based on hospital-acquired-condition measures?
- A. Hospital-Acquired Condition Reduction Program
- B. Inpatient Psychiatric Facility Quality Reporting Program
- C. Hospital Value-Based Purchasing Program
- D. Medicare Shared Savings Program
Correct Answer: A 🗳️
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A pregnant patient is admitted at 30 weeks' gestation with acute pyelonephritis complicating pregnancy.
Which general sequencing principle applies?
- A. Pyelonephritis is always sequenced before any obstetric code
- B. The appropriate Chapter 15 pregnancy complication code generally receives sequencing priority
- C. A symptom code must be principal diagnosis
- D. Pregnancy is ignored because the infection is unrelated to delivery
Correct Answer: B 🗳️
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