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ACDIS Certified Clinical Documentation Specialist Sample Questions:
A hospital's mortality report shows 125 observed deaths and 100 expected deaths. The observed-to-expected mortality ratio is 1.25. Which interpretation is MOST accurate?
- A. The hospital's mortality performance exactly matches expected mortality
- B. Observed mortality is 25% higher than expected
- C. Expected mortality is 125% higher than observed
- D. Observed mortality is 25% lower than expected
Correct Answer: B 🗳️
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A hospital reports 80 observed deaths when its risk-adjustment methodology predicted 100 expected deaths.
What is the observed-to-expected mortality ratio, and what does it indicate?
- A. 0.80; observed deaths are 80% above expected
- B. 1.25; observed deaths are 25% below expected
- C. 1.25; observed deaths are 25% above expected
- D. 0.80; observed deaths are 20% below expected
Correct Answer: D 🗳️
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A pregnant female presents to the ED with diarrhea, cramps, nausea, and vomiting for the past 12 hours. She was admitted with enteritis due to Clostridium difficile and provided IV fluids. Which of the following coding guidelines applies to determining the principal diagnosis for this patient?
- A. signs & symptoms, and ill-defined condition codes
- B. infectious and parasitic codes
- C. complications of pregnancy, childbirth, and puerperium codes
- D. sequencing related to etiology manifestation codes
Correct Answer: C 🗳️
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A patient with an indwelling urinary catheter develops fever, pyuria, and a positive urine culture during hospitalization. The physician documents "UTI" but does not state whether the infection is related to the catheter. What should the CDI specialist do?
- A. Remove the UTI because catheterized patients commonly have bacteriuria
- B. Code a catheter complication whenever a urine culture is positive
- C. Automatically classify the UTI as catheter-associated because the catheter is present
- D. Query the provider to clarify whether a cause-and-effect relationship exists
Correct Answer: D 🗳️
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A patient is admitted with a stage 3 sacral pressure ulcer. During hospitalization, the wound deteriorates and is documented as stage 4 at the same site. Which reporting approach is appropriate?
- A. Report only stage 4 because it is the highest stage
- B. Report codes representing the stage on admission and the highest stage reached during the stay
- C. Use an unstageable pressure-ulcer code
- D. Report only stage 3 because that was the POA stage
Correct Answer: B 🗳️
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