最新的ACDIS Certified Clinical Documentation Specialist - CCDS免費考試真題
A registered dietitian documents severe malnutrition based on substantial weight loss, severe muscle depletion, and prolonged inadequate energy intake. The attending physician documents only "poor oral intake." What is the BEST action for the CDI specialist?
正確答案: C
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A patient with a history of heart failure is admitted with severe dyspnea and bilateral lower-extremity edema.
BNP is 1,000 pg/mL and echocardiography shows an ejection fraction of 25% with left ventricular systolic dysfunction. Which diagnosis should the CDI specialist consider when constructing a clinically supported clarification query?
BNP is 1,000 pg/mL and echocardiography shows an ejection fraction of 25% with left ventricular systolic dysfunction. Which diagnosis should the CDI specialist consider when constructing a clinically supported clarification query?
正確答案: D
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A patient is admitted with sepsis due to osteomyelitis and evidence of organ failure. Which of the following is the correct principal diagnosis?
正確答案: D
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The amount of the IPPS Indirect Medical Education Adjustment is determined by teaching intensity as measured by the hospital's number of residents compared to:
正確答案: C
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A patient with an indwelling central venous catheter develops fever and positive blood cultures for Staphylococcus aureus. The physician documents "bacteremia" but does not establish whether the catheter caused the infection. Which action is MOST appropriate?
正確答案: C
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A patient presents with fever, productive cough, and infiltrates in the right upper lobe per chest x-ray. The history and physical notes that the patient has pneumonia and hypotension. Cultures are drawn and the patient is admitted for IV antibiotics. On day 2, the patient's condition worsens, and the patient is transferred to the ICU for closer monitoring. The ICU physician documents sepsis. Which of the following statements is MOST accurate?
正確答案: A
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A patient develops chest pain and elevated troponins while receiving care in the emergency department. The physician diagnoses an NSTEMI. Several hours later, an inpatient admission order is written. How should the NSTEMI generally be considered for POA purposes?
正確答案: A
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A patient with sepsis has acute confusion, impaired attention, fluctuating mental status, and no focal neurologic findings. CT of the head is negative. The provider documents only "AMS secondary to infection." Which clarification would be MOST clinically appropriate?
正確答案: C
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A patient's baseline creatinine is 1.1 mg/dL. On admission it is 1.2 mg/dL, and 36 hours later it rises to 2.4 mg
/dL after prolonged hypotension. Urine output declines substantially. Which condition presents the strongest clarification opportunity?
/dL after prolonged hypotension. Urine output declines substantially. Which condition presents the strongest clarification opportunity?
正確答案: A
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Which of the following is a characteristic of a reportable secondary diagnosis?
正確答案: B
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A patient underwent open small bowel resection with anastomosis for colon cancer. The physician notes,
"Post-op ileus, awaiting return of bowel function." Which of the following actions should a CDI specialist take FIRST?
"Post-op ileus, awaiting return of bowel function." Which of the following actions should a CDI specialist take FIRST?
正確答案: A
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The MOST important factor influencing a hospital's ability to capture the most accurate MS-DRG involves:
正確答案: C
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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?
正確答案: C
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A patient undergoes total knee replacement. The patient has no DVT on admission but develops a postoperative deep vein thrombosis during the hospitalization. Why is accurate POA documentation particularly important?
正確答案: B
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A patient accidentally takes twice the prescribed dose of warfarin and develops gastrointestinal bleeding.
Which coding concept applies?
Which coding concept applies?
正確答案: C
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