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Free Certified Clinical Documentation Specialist Practice Questions

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Exam style questions across every CCDS domain

Last Update 4 days ago
Total Questions : 150

Start with our free CCDS practice questions, carefully crafted to mirror the domains, phrasing, and difficulty of the real Clinical Documentation Specialist exam. Each CCDS exam question comes with a detailed rationale that explains not just which answer is correct but why the others fall short. That's how concepts stick. Use the free set to benchmark yourself: identify your ACDIS weak domains, see where you're losing marks, and build a focused study plan in minutes.

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Question # 11

A hospital records 72 observed deaths, while its risk-adjustment model predicts 90 expected deaths. What is the observed-to-expected mortality ratio?

Options:

A.  

0.80

B.  

1.20

C.  

1.25

D.  

1.80

Discussion 0
Question # 12

A patient with metastatic lung cancer is admitted solely for treatment of anemia caused by chemotherapy. The patient receives packed red blood cells and no treatment directed at the malignancy. Which diagnosis should be sequenced first?

Options:

A.  

Lung cancer

B.  

Metastatic disease

C.  

Anemia due to chemotherapy

D.  

Adverse effect of chemotherapy

Discussion 0
Question # 13

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?

Options:

A.  

Code only the respiratory symptoms

B.  

Code aspiration pneumonia as if established

C.  

Query because “probable” diagnoses can never be coded

D.  

Code unspecified pneumonia only

Discussion 0
Question # 14

A patient with active breast cancer is admitted solely to receive a scheduled cycle of antineoplastic chemotherapy. No complication or acute disease process is responsible for the admission. Which diagnosis is generally sequenced first?

Options:

A.  

Breast cancer

B.  

Encounter for antineoplastic chemotherapy

C.  

Immunosuppression

D.  

Malignancy-related fatigue

Discussion 0
Question # 15

A patient is admitted with alcohol intoxication. The H & P notes increased tolerance related to alcohol consumption, desire to drink despite impaired liver functions, and unsuccessful attempts to stop drinking. Identify the query opportunity related to alcohol consumption.

Options:

A.  

Withdrawal

B.  

Delirium tremens

C.  

Dependence

D.  

Abuse

Discussion 0
Question # 16

Which of the following conditions demonstrates the greatest risk of mortality in a 77-year-old patient?

Options:

A.  

History of tobacco use, admitted with COPD exacerbation and respiratory failure

B.  

History of hypertension and diabetes mellitus, admitted with NSTEMI with acute systolic heart failure

C.  

History of diabetes mellitus, admitted with UTI and metabolic encephalopathy

D.  

History of mastectomy 10 years ago, admitted with sepsis and a UTI

Discussion 0
Question # 17

A patient who underwent abdominal surgery one week ago is readmitted specifically for treatment of a postoperative wound infection documented by the surgeon as a complication of the procedure. Which condition should generally be considered for principal diagnosis selection?

Options:

A.  

The original condition that required surgery

B.  

The postoperative wound infection/complication

C.  

Fever

D.  

Abdominal pain

Discussion 0
Question # 18

A CDI specialist drafts the following query:

“Please document acute respiratory failure because the patient's oxygen saturation is 84% and this diagnosis will qualify as an MC

C.  

”

What is the MOST appropriate action?

Options:

A.  

Submit the query because the clinical indicator is valid

B.  

Remove the reimbursement language and construct a neutral clinically supported query

C.  

Submit the query only after obtaining coding-manager approval

D.  

Replace “MCC” with “CC” and submit the query

Discussion 0
Question # 19

The MOST important factor influencing a hospital's ability to capture the most accurate MS-DRG involves:

Options:

A.  

Complete clinical documentation

B.  

Capture of clinical quality indicators

C.  

Capture of patient satisfaction indicators

D.  

Complete POA documentation

Discussion 0
Question # 20

A wound care nurse documents an assessment and care of a pressure ulcer. For coding purposes, the wound care nurse's documentation can be used to assign which of the following?

Options:

A.  

POA status

B.  

The diagnosis

C.  

Location

D.  

Stage

Discussion 0

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