CCDS ACDIS Certified Clinical Documentation Specialist Free Practice Exam Questions (2026 Updated)

The appropriate action is to query the provider regarding the patient's nutritional diagnosis. The dietitian's assessment supplies important clinical evidence, but the associated diagnosis of malnutrition generally must be documented by an appropriate provider before the diagnosis code is assigned.

The FY 2026 ICD-10-CM Official Guidelines permit selected elements to come from non-provider clinicians—such as BMI, pressure-ulcer stage, coma scale, NIH Stroke Scale, certain social determinants, and other specifically identified exceptions. Malnutrition diagnosis itself is not simply assigned solely from a dietitian's diagnostic statement under this general rule.

Ignoring the dietitian's findings would also be inappropriate. CDI review should integrate multidisciplinary documentation because such documentation can reveal valid clarification opportunities. Severe weight loss, reduced intake, and documented muscle depletion provide a clinical basis for a neutral query.

The query should not state that severe malnutrition “must” be documented because it is an MCC. Instead, it should present the relevant nutrition findings and allow the provider to determine the diagnosis, including severe malnutrition, another level of malnutrition, another cause, or inability to determine.

CCDS Reference Topics: Malnutrition; multidisciplinary documentation; provider diagnosis requirements; clinical indicators.

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The provider query response rate most directly measures whether physicians are responding to CDI clarification requests. It evaluates participation in the query process regardless of whether the provider agrees with the diagnosis suggested by the clinical circumstances.

This distinction is important. A high agreement rate is not necessarily the goal of a compliant CDI program. Providers should be free to disagree, document an alternative condition, state that a diagnosis was ruled out, or indicate that the issue cannot be determined. A very high response rate combined with clinically independent responses represents stronger engagement than an artificial focus on agreement.

Case mix index measures the average relative resource intensity of the hospital's MS-DRGs and is influenced by numerous clinical, coding, surgical, and case-mix factors. CC capture reflects diagnosis severity patterns but does not directly demonstrate physician responsiveness. CDI review rate is primarily a departmental workflow/productivity measure.

The official CCDS content outline specifically lists provider response rates, CMI, CDI productivity metrics, physician-performance measurement, and longitudinal trending among CDI program-analysis competencies.

A mature program should analyze response rate by service line, provider, query type, response time, and escalation frequency.

CCDS Reference Topics: Provider response rate; physician engagement; CDI analytics; query metrics; program performance.

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The current NSTEMI is the acute condition driving the admission. The prior type 2 myocardial infarction occurred 30 days earlier, placing it beyond the ICD-10-CM four-week acute-MI reporting window. The Official Guidelines state that category I21 codes may continue to be reported while an MI is four weeks old or less; after that period, an aftercare code may be appropriate when continued MI-related care is being provided, or I25.2 may describe an old/healed MI when applicable.

There is an additional reason not to select a “subsequent MI” answer. Category I22 is restricted to qualifying subsequent type 1 or unspecified acute myocardial infarctions occurring within four weeks of the initial qualifying MI. Type 2 MI is classified to I21.A1 rather than I22.

Therefore, the previous type 2 MI does not support selection of a subsequent-MI option in this 30-day scenario. The active NSTEMI is the diagnosis relevant to the working MS-DRG. “Initial encounter” in answer B is exam terminology rather than an ICD-10-CM seventh-character designation for MI, but B is clearly the intended correct choice.

CCDS Reference Topics: Official Guidelines—acute myocardial infarction; working MS-DRG; circulatory disorders.

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Among the choices presented, sepsis associated with a urinary tract infection represents the strongest overall mortality-risk condition. Sepsis is a systemic, potentially life-threatening response to infection and is associated with substantially greater mortality risk than an uncomplicated localized infection, particularly in an elderly patient.

Risk of mortality in CDI is not determined merely by whether a diagnosis is a CC or MCC. Risk-adjustment systems evaluate the complete clinical profile, including principal diagnosis, secondary diagnoses, age, organ dysfunction, severity interactions, and other patient characteristics. Thus, reimbursement severity and predicted mortality are related concepts but are not interchangeable.

The history of mastectomy ten years earlier does not itself materially increase the current acute severity unless active malignancy or another relevant condition is present. The principal acute concern in option D is sepsis. COPD with respiratory failure and NSTEMI with acute systolic heart failure are also high-risk presentations and require complete documentation; however, the question's intended risk-adjustment comparison identifies the septic presentation as carrying the greatest mortality concern.

If acute organ dysfunction were linked to sepsis, documentation of severe sepsis would further increase the represented clinical severity.

CCDS Reference Topics: Risk of mortality; severity adjustment; sepsis; quality reporting; distinction between MS-DRG severity and ROM.

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Among the listed diagnoses, acute diastolic heart failure has the greatest potential MS-DRG impact because ICD-10-CM code I50.31 is classified as an MCC under the FY 2026 CMS MS-DRG system. CMS specifically identifies I50.31 as an MCC, whereas diagnoses classified only as a CC generally produce a lower severity level within DRG families that distinguish no CC/MCC, CC, and MCC cases.

Acute kidney injury, commonly represented by N17.9 when unspecified, is generally a CC rather than an MCC; CMS examples demonstrate N17.9 functioning as a CC in MS-DRG assignment. COPD with acute exacerbation and many delirium diagnoses may also affect severity assignment, but they do not exceed the MCC effect of qualifying acute heart failure in the standard hierarchy represented here.

The wording “monetary impact” must not be interpreted as permission to pursue diagnoses for financial gain. CDI professionals should query only when clinical indicators justify clarification. Reimbursement is a consequence of accurate documentation and coding, not the clinical justification for creating a diagnosis.

The actual payment impact also depends on the principal diagnosis, existing MCCs, procedures, payer methodology, and final MS-DRG.

CCDS Reference Topics: CC/MCC hierarchy; MS-DRG reimbursement; acute heart failure; compliant CDI practice.

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Severe protein-calorie malnutrition is the correct answer. This question is adapted from an official CCDS sample question published by ACDIS.

Under the FY 2026 MS-DRG Definitions Manual, E43, unspecified severe protein-calorie malnutrition, is classified as an MCC. In contrast, moderate and mild protein-calorie malnutrition codes are classified as CCs rather than MCCs.

An MCC can materially affect MS-DRG assignment when the applicable DRG family differentiates cases by MCC status and when no exclusion or other grouper rule prevents the effect. However, the financial effect is never sufficient justification for a query. Documentation must be clinically supported and reflect the patient's actual condition.

A dietitian may document detailed nutrition findings and malnutrition criteria, but the reportable diagnosis ordinarily requires documentation by the provider responsible for establishing diagnoses. Therefore, when strong nutritional indicators exist but the provider has not documented malnutrition, a compliant query may be appropriate.

For CCDS preparation, candidates should understand both the clinical characteristics of malnutrition and its coding/reimbursement classification.

CCDS Reference Topics: MCCs; malnutrition; MS-DRG methodology; documentation requirements; IPPS.

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CMS publishes the complete MCC and CC lists as part of the FY 2026 IPPS Final Rule supporting tables. Specifically, the FY 2026 final-rule page identifies Table 6I as the Complete MCC List and Table 6J as the Complete CC List, along with additions, deletions, and the CC exclusion list.

These files are critical reference resources when assessing MS-DRG severity logic. Nevertheless, classification as an MCC or CC does not automatically mean that the diagnosis changes a particular case's MS-DRG. Principal-diagnosis exclusions, procedure logic, DRG structure, and the presence of another MCC can affect whether a diagnosis alters final assignment.

The Hospital Consumer Assessment survey relates to patient experience rather than diagnosis severity classification. The Physician Fee Schedule governs professional reimbursement and does not contain the inpatient MS-DRG MCC/CC classification system. National Coverage Determinations address Medicare coverage for particular services rather than MS-DRG severity categories.

CDI specialists should use the current CMS version applicable to the discharge date. CMS identifies MS-DRG Version 43.1 as effective April 1 through September 30, 2026.

CCDS Reference Topics: MCC; CC; CMS Definitions Manual; IPPS; MS-DRG severity.

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ICD-10-CM provides category I22 for a subsequent acute myocardial infarction occurring within four weeks—28 days—of an initial acute MI, when the qualifying MI types and circumstances meet the classification requirements.

The FY 2026 Official Guidelines specify that when a patient with a type 1 or unspecified acute MI experiences a new type 1 or unspecified MI within four weeks of the initial MI, a code from category I22 is used together with the appropriate I21 code. Sequencing depends on the circumstances of the encounter.

This rule requires care because type 2 MI and certain other myocardial infarction classifications do not follow the same I22 subsequent-MI logic. CDI specialists therefore need accurate documentation of MI type, anatomic location when applicable, timing, and whether the current event represents a genuinely new infarction rather than ongoing care for the original MI.

The prior STEMI does not become an “old MI” merely because the patient left the hospital; the ICD-10-CM acute MI period extends for four weeks from onset.

CCDS Reference Topics: Acute MI; subsequent MI; I21/I22; four-week rule; cardiovascular coding.

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The documentation does not clearly establish the definitive condition chiefly responsible for the inpatient admission. The patient has chest pain, borderline troponin elevation, and a history of GERD, while the physician describes the symptoms only as “likely GI in origin.” The appropriate CDI action is therefore to clarify the condition responsible for the admission rather than independently select GERD or myocardial infarction.

A history of GERD does not establish that GERD caused the present chest pain. Likewise, borderline troponin elevation alone does not establish an AMI, so a query that directs the provider toward AMI would be inappropriate without stronger clinical support.

For inpatient coding, uncertain diagnoses documented at discharge using terms such as “probable,” “suspected,” or “likely” may be coded as though established. However, the phrase “GI in origin” still fails to identify a specific gastrointestinal disease responsible for the admission. The CDI specialist's purpose is to obtain clinically meaningful diagnostic clarification rather than infer a diagnosis from treatment such as omeprazole.

A compliant query should include the relevant symptoms, diagnostic findings, treatment, and supported alternatives without indicating financial consequences.

CCDS Reference Topics: Principal diagnosis clarification; ambiguous documentation; compliant querying; clinical indicators.

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POA indicator U means that the documentation is insufficient to determine whether the condition was present on admission.

This is different from Y, which indicates that the condition was present when inpatient admission occurred, and N, which indicates that the condition was not present at admission. Indicator W is used when the provider is unable to clinically determine whether the condition was present at the time of inpatient admission.

The distinction between U and W is especially important. U reflects inadequacy of the documentation, whereas W reflects a clinical determination that the timing cannot be established despite appropriate evaluation.

CDI specialists should generally attempt to resolve unclear timing when clinically feasible before a case reaches final coding. Accurate POA assignment can influence CMS Hospital-Acquired Condition payment logic and quality measurement.

CMS publishes an annual list of diagnoses exempt from POA reporting and maintains the FY 2026 POA resources separately from the HAC code lists.

POA reporting focuses on the condition's status at inpatient admission, not merely when it was first documented or when diagnostic confirmation became available.

CCDS Reference Topics: POA indicators; U versus W; HACs; admission timing; inpatient reporting.

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Increased nursing care is specifically included in the UHDDS/ICD-10-CM definition of a clinically significant reportable secondary diagnosis. A secondary condition is reportable when it affects patient care by requiring clinical evaluation, therapeutic treatment, diagnostic procedures, an extended length of stay, or increased nursing care and/or monitoring.

This distinction prevents conditions that merely appear in the record but have no relevance to the current encounter from automatically becoming reportable secondary diagnoses. For example, a historical diagnosis that does not influence treatment, monitoring, evaluation, or length of stay generally should not be coded simply because it appears in a problem list.

Option A is imprecise. A secondary condition may extend the hospitalization, but it does not need to be the condition that originally “required hospital stay.” Option B is the opposite of the guideline criterion, which refers to extended, not decreased, length of stay. Option C is also insufficient by itself: provider documentation establishes diagnoses, but documentation alone does not necessarily make every historical or clinically irrelevant condition reportable.

CDI specialists must therefore evaluate both provider documentation and the clinical significance of secondary conditions.

CCDS Reference Topics: Reporting additional diagnoses; UHDDS; secondary diagnosis criteria; resource utilization.

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When an admission is specifically for treatment of anemia associated with an adverse effect of chemotherapy or immunotherapy, and treatment is directed only at the anemia, the anemia diagnosis is sequenced first.

The FY 2026 ICD-10-CM Official Guidelines distinguish chemotherapy-related anemia from anemia caused directly by the malignancy. For chemotherapy-associated anemia, the anemia code is sequenced first, followed by the appropriate neoplasm code and the applicable adverse-effect code for the antineoplastic drug.

This differs significantly from anemia associated with the malignancy itself. If the patient is admitted solely to manage anemia caused by the malignancy, the malignancy is sequenced first, followed by the anemia-in-neoplastic-disease code.

The adverse-effect code is required to explain the medication-related cause, but it is not sequenced before the manifestation in this scenario because adverse-effect coding follows the nature of the adverse effect first.

For CDI specialists, accurate documentation of the cause of anemia—malignancy, chemotherapy, bleeding, chronic disease, nutritional deficiency, or another condition—is therefore essential because etiologic specificity can directly change sequencing.

CCDS Reference Topics: Chemotherapy adverse effects; anemia; neoplasm coding; principal diagnosis; sequencing.

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The clinical presentation most strongly supports clarification of hypovolemic shock, specifically hemorrhagic shock in the context of traumatic splenic bleeding. Profound hypotension at 80/60 mmHg, extreme tachycardia at 160 beats/min, substantial crystalloid resuscitation, transfusion of three units of packed red blood cells, and vasopressor support demonstrate severe circulatory compromise.

Acute blood loss anemia may also be present and should be documented when clinically supported, but it does not fully represent the patient's hemodynamic instability. Shock describes failure of effective tissue perfusion and therefore more accurately captures the immediate physiologic severity.

SIRS due to trauma is less specific than the evident volume-loss state and would not adequately describe the hemorrhagic circulatory collapse. The record already identifies splenic laceration; “ruptured spleen” should not be substituted without provider confirmation and appropriate operative/imaging evidence.

For CDI purposes, this is a classic situation in which documentation of only the anatomical injury understates the patient's physiologic acuity. A neutral query can present the documented hypotension, tachycardia, transfusion, fluids, and vasoactive treatment and request clarification of the associated condition.

CCDS Reference Topics: Shock; trauma; hemorrhage; acute blood loss; severity-of-illness documentation.

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Sepsis resulting from a postprocedural infection follows specialized sequencing rules. The code identifying the postprocedural infection or surgical-site infection is sequenced first when applicable, followed by the code for sepsis following a procedure and any additional codes required for the infectious organism or severe sepsis.

The FY 2026 Official Guidelines specifically state that for sepsis following a postprocedural wound or surgical-site infection, the appropriate postprocedural infection code is sequenced first. An additional code for sepsis following a procedure is then assigned. If severe sepsis exists, the appropriate R65.2- code and codes for acute organ dysfunction are additionally reported.

This differs from ordinary sepsis due to a localized infection, where the systemic infection is typically sequenced before the localized infection when sepsis is the reason for admission.

The cause-and-effect relationship is also essential. A wound infection merely occurring after surgery does not automatically establish a postprocedural complication. Here, the surgeon has explicitly documented that relationship, so the necessary clinical linkage is present.

CCDS Reference Topics: Postprocedural infection; sepsis; surgical-site infection; complication coding; sequencing.

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Case mix index is calculated as:

Total MS-DRG relative weights ÷ Total inpatient discharges

Therefore:

4,375 ÷ 2,500 = 1.75

The hospital's CMI is 1.75.

CMI provides an aggregate indication of the average relative resource intensity of the hospital's inpatient population. Because each MS-DRG carries a relative weight, hospitals treating larger numbers of complex medical or surgical cases typically have higher CMIs than hospitals treating less resource-intensive populations.

CMI is not a direct quality score and should not be interpreted as a pure measure of CDI performance. It can change because of service-line mix, surgical volume, patient acuity, transfers, annual MS-DRG recalibration, coding accuracy, documentation quality, and other operational changes.

CMS maintains the FY 2026 MS-DRG Definitions Manual and grouper logic, currently Version 43.1 for April 1 through September 30, 2026.

A CDI manager should therefore analyze unexpected CMI changes alongside service-line trends, query activity, coding reconciliation, procedure volumes, and diagnosis patterns.

CCDS Reference Topics: CMI; relative weights; CDI analytics; MS-DRGs; trend analysis.

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The most effective intervention is targeted, service-line-specific physician education based on actual documentation trends and clinically relevant examples.

Repeated queries for the same issue usually indicate a systematic documentation opportunity rather than isolated provider mistakes. Education should therefore show cardiologists how documentation of heart-failure type—such as systolic, diastolic, or combined—and acuity—acute, chronic, or acute on chronic—communicates the patient's clinical condition more precisely.

Using deidentified examples from the service line makes the education immediately relevant and enables physicians to recognize which clinical circumstances frequently generate clarification. Aggregate query data can demonstrate where documentation gaps occur without criticizing individual providers.

Sending an entire code book places coding responsibility on physicians and is unlikely to change documentation behavior. Stopping queries leaves unresolved clinical ambiguity. Framing the education around reduced reimbursement is also inappropriate because the goal of CDI education is accurate clinical representation, not coaching physicians toward higher-paying diagnoses.

The 2026 ACDIS/AHIMA query guidance identifies accurate representation of the patient's clinical status as the underlying purpose of CDI clarification.

CCDS Reference Topics: Physician education; communication; heart-failure specificity; query trend analysis.

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ICD-10-CM Chapter 15 codes generally have sequencing priority over codes from other chapters when a condition complicates pregnancy, childbirth, or the puerperium.

Therefore, when pyelonephritis complicates pregnancy, the appropriate obstetric complication code is generally sequenced first, with additional code(s) used as instructed to identify the specific infection or organism.

This principle is important because ordinary principal-diagnosis logic can be modified by chapter-specific instructions. CDI specialists working with obstetric cases therefore must determine whether the pregnancy affects management and whether the condition is documented as complicating pregnancy.

The only major exception would be when the provider specifically determines that the pregnancy is incidental to the encounter and the applicable coding requirements for incidental pregnancy are met.

A symptom code does not generally supersede an established definitive diagnosis. Likewise, the fact that an infection could occur outside pregnancy does not negate Chapter 15 sequencing when it is complicating the pregnancy.

Correct gestational-age documentation is also important because an additional code may be required to identify the specific week of gestation.

CCDS Reference Topics: Obstetric coding; Chapter 15; sequencing priority; infection in pregnancy; principal diagnosis.

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A significant mismatch rate should trigger structured CDI/coding reconciliation, not an assumption that either department is wrong.

Working MS-DRGs are provisional. Final coding may change because of discharge-summary diagnoses, operative reports, pathology results, late physician clarification, Coding Clinic guidance, sequencing conventions, final procedure coding, CC/MCC exclusions, or other grouper logic unavailable during the concurrent CDI review.

The manager should categorize mismatch causes. Useful categories include principal-diagnosis differences, missed secondary diagnoses, procedure-code differences, coding-guideline interpretation, query results, discharge documentation, and technical grouper issues.

Patterns can then identify whether education is needed for CDI specialists, coding professionals, physicians, or multiple groups.

Requiring coding staff to adopt the CDI working DRG would undermine coding independence and final coding accountability. Excluding mismatches from metrics would conceal an important quality indicator.

CMS confirms that the FY 2026 MS-DRG Definitions Manual contains the complete grouper logic for Version 43.1, making current grouper rules essential when evaluating discrepancies.

CCDS Reference Topics: MS-DRG reconciliation; CDI/coder agreement; program analysis; education; grouper logic.

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The wound care nurse's documentation may be used to establish the stage of a pressure ulcer, making option D correct. ICD-10-CM provides specific exceptions to the general rule that diagnosis code assignment is based on documentation by a provider legally accountable for establishing diagnoses. Pressure-ulcer staging is one of the clinical details that may be derived from documentation by qualified non-provider clinicians involved in the patient's care.

Wound care nurses possess specialized expertise in pressure-injury assessment and commonly document staging based on tissue involvement. Current ICD-10-CM guidance directs assignment of the pressure-ulcer stage according to clinical documentation and provides specific rules for unstageable ulcers, healing ulcers, and ulcers that progress during hospitalization.

This exception does not mean that a wound-care nurse independently establishes every element of the medical diagnosis for coding purposes. The provider documentation remains central to identifying the pressure-ulcer diagnosis and relevant clinical condition, while the stage may come from qualified clinician documentation.

POA assignment follows separate reporting rules and is based on whether the condition was present at the time inpatient admission occurred.

CCDS Reference Topics: Pressure ulcers; non-provider documentation; staging; coding conventions.

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