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ACDIS Certified Clinical Documentation Specialist Sample Questions:
Which of the following principal diagnoses groups to MS-DRG 884, Organic Disturbances and Intellectual Disability?
- A. Alzheimer's dementia
- B. Wernicke dementia
- C. Vascular dementia
- D. Alcohol-induced dementia
Correct Answer: C 🗳️
Explanation: Only visible for Prep4sures members. You can sign-up / login (it's free).
A patient is admitted with a stage 4 pressure ulcer of the right heel. The physician documents the pressure- ulcer diagnosis and location. The wound-care nurse documents stage 4. Which statement is MOST accurate?
- A. Stage 4 cannot be coded unless the physician documents the stage personally
- B. The nurse may establish both the pressure-ulcer diagnosis and all associated medical diagnoses
- C. Pressure-ulcer stage is irrelevant to coding
- D. Qualified non-provider documentation may be used to identify the pressure-ulcer stage
Correct Answer: D 🗳️
Explanation: Only visible for Prep4sures members. You can sign-up / login (it's free).
At discharge, the attending physician documents, "Probable aspiration pneumonia causing the patient's respiratory symptoms." The patient is an inpatient. No subsequent documentation rules out aspiration pneumonia. How should the diagnosis be handled for inpatient coding?
- A. Code aspiration pneumonia as if established
- B. Code unspecified pneumonia only
- C. Query because "probable" diagnoses can never be coded
- D. Code only the respiratory symptoms
Correct Answer: A 🗳️
Explanation: Only visible for Prep4sures members. You can sign-up / login (it's free).
A patient presents to the ED following a motor vehicle crash with a lacerated spleen. The patient's BP is 80
/60, HR is 160, and the patient receives dopamine, a 2-L saline bolus, and 3 units of PRBCs. The physician documents MVA with lacerated spleen. Based on these clinical indicators, which of the following conditions would BEST reflect the accurate acuity of this patient?
- A. Acute blood loss anemia
- B. Ruptured spleen
- C. Hypovolemic shock
- D. SIRS due to trauma
Correct Answer: C 🗳️
Explanation: Only visible for Prep4sures members. You can sign-up / login (it's free).
A patient has chronic gastroesophageal reflux disease listed in the past medical history. During the current hospitalization for bacterial pneumonia, GERD receives no clinical evaluation, treatment, diagnostic testing, increased nursing monitoring, or effect on length of stay. Which statement is MOST accurate?
- A. GERD must be coded because it appears in the medical record
- B. GERD generally does not meet the criteria for a reportable secondary diagnosis
- C. GERD must be coded because it is a chronic disease
- D. GERD should be coded only if it is a CC
Correct Answer: B 🗳️
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