CCDS PRACTICE 100 EXAM QUESTIONS AND ANSWERS
UPDATED 2026/2027 || CLINICAL DOCUMENTATION
IMPROVEMENT SPECIALIST REVIEW || ICD-10-CM/PCS, MS-
DRG & COMPLIANCE || VERIFIED QUESTIONS WITH
ACCURATE ANSWERS || HIGH-YIELD STUDY GUIDE ||
GRADED A+
100 exam questions with answers
A. Bleeding gastric ulcer - CORRECT ANSWER -A patient is admitted from
the emergency department (ED) with a diagnosis of weakness and anemia. After
admission and further treatment with packed red blood cells (PRBC), GI
consult, and endoscopy, the physician includes the following diagnoses in the
discharge summary: anemia, suspected bleeding gastric ulcer, and GERD. What
would be the most appropriate principle diagnosis?
A. Bleeding gastric ulcer
B. Anemia
C. GERD
D. Weakness
B. Neoplasm of occipital region - CORRECT ANSWER -A patient is
admitted with new-onset seizures. Head CT reveals a mass in the occipital
region. The physician documents possible brain tumor, and the patient is
transferred to another hospital for further workup. What would be the most
appropriate principal diagnosis based upon this documentation?
A. Seizure
B. Neoplasm of occipital region
C. Head mass
D. Head tumor
C. 1,2, and 3
,1. Calculated annually
2. Dependent upon indirect costs for graduate medical education and new
technology
3. Adjusted based upon number of low-income patients cared for - CORRECT
ANSWER -A hospital's base rate or blended rate is:
1. Calculated annually
2. Dependent upon indirect costs for graduate medical education and new
technology
3. Adjusted based upon number of low-income patients cared for
4. Not adjusted based upon capital expenses
A. 1 and 2
B. 2 and 3
C. 1,2, and 3
D. 1,2,3, and 4
D. Reflect the severity of illness (SOI) and resource consumption of the
patient's care - CORRECT ANSWER -The final MS-DRG assigned to a
patient's medical record should:
A. Reflect the amount of time the physician spent with the patient
B. Depend upon the patient's length of stay
C. Be assigned by the physician
D. Reflect the severity of illness (SOI) and resource consumption of the
patient's care
C. Poisoning - CORRECT ANSWER -A patient is admitted from the
emergency department with the diagnosis of acute respiratory failure due to
,overdose of pain medication and an aspiration pneumonia. What is the principal
diagnosis?
A. Acute respiratory failure
B. Aspiration pneumonia
C. Poisoning
D. Adverse effect of medication
D. All of the conditions should be coded - CORRECT ANSWER -A patient is
admitted with pneumonia, stage 1 chronic renal failure, chronic anemia, and
COPD, While hospitalized the patient receives IV antibiotics, inhalers, oxygen,
IV fluids at 50mL/hr, and iron tablets. Keeping the guidelines for coding of
secondary diagnoses in mind, which condition should be coded?
A. Pneumonia only
B. Pneumonia and COPD only
C. Pneumonia, COPD, and anemia
D. All of the conditions should be coded
D. Fractured ulna - CORRECT ANSWER -Which of the following is an
example of a hospital-acquired condition?
A. Fat embolism
B. IV phlebitis
C. Pneumonia
D. Fractured ulna
C. A diagnosis that is listed as possible in the history and physical - CORRECT
ANSWER -Which of the following is an example of documentation that would
meet the present on admission criteria for coding?
, A. A diagnosis that is indicated in the history and physical and ruled out in the
discharge summary
B. A diagnosis found in a previous medical record
C. A diagnosis that is listed as possible in the history and physical
D. An acute condition identified on the third day of admission
A. Colon cancer - CORRECT ANSWER -A patient is admitted with
abdominal pain and the history and physical indicated a diagnosis of probable
colon cancer. On day two, the physician documents acute renal failure in the
progress notes and the patient receives IV fluids. The discharge summary lists
possible metastatic colon cancer and acute renal failure. The principal diagnosis
would be:
A. Colon cancer
B. Acute renal failure
C. Abdominal pain
D. Metastatic neoplasm of the colon
D. 1,2, and 3
1. Include identification of the patient's SOI
2. Identify conditions that are present on admission
3. Support medical necessity - CORRECT ANSWER -Accurate
documentation should:
1. Include identification of the patient's SOI
2. Identify conditions that are present on admission
3. Support medical necessity
UPDATED 2026/2027 || CLINICAL DOCUMENTATION
IMPROVEMENT SPECIALIST REVIEW || ICD-10-CM/PCS, MS-
DRG & COMPLIANCE || VERIFIED QUESTIONS WITH
ACCURATE ANSWERS || HIGH-YIELD STUDY GUIDE ||
GRADED A+
100 exam questions with answers
A. Bleeding gastric ulcer - CORRECT ANSWER -A patient is admitted from
the emergency department (ED) with a diagnosis of weakness and anemia. After
admission and further treatment with packed red blood cells (PRBC), GI
consult, and endoscopy, the physician includes the following diagnoses in the
discharge summary: anemia, suspected bleeding gastric ulcer, and GERD. What
would be the most appropriate principle diagnosis?
A. Bleeding gastric ulcer
B. Anemia
C. GERD
D. Weakness
B. Neoplasm of occipital region - CORRECT ANSWER -A patient is
admitted with new-onset seizures. Head CT reveals a mass in the occipital
region. The physician documents possible brain tumor, and the patient is
transferred to another hospital for further workup. What would be the most
appropriate principal diagnosis based upon this documentation?
A. Seizure
B. Neoplasm of occipital region
C. Head mass
D. Head tumor
C. 1,2, and 3
,1. Calculated annually
2. Dependent upon indirect costs for graduate medical education and new
technology
3. Adjusted based upon number of low-income patients cared for - CORRECT
ANSWER -A hospital's base rate or blended rate is:
1. Calculated annually
2. Dependent upon indirect costs for graduate medical education and new
technology
3. Adjusted based upon number of low-income patients cared for
4. Not adjusted based upon capital expenses
A. 1 and 2
B. 2 and 3
C. 1,2, and 3
D. 1,2,3, and 4
D. Reflect the severity of illness (SOI) and resource consumption of the
patient's care - CORRECT ANSWER -The final MS-DRG assigned to a
patient's medical record should:
A. Reflect the amount of time the physician spent with the patient
B. Depend upon the patient's length of stay
C. Be assigned by the physician
D. Reflect the severity of illness (SOI) and resource consumption of the
patient's care
C. Poisoning - CORRECT ANSWER -A patient is admitted from the
emergency department with the diagnosis of acute respiratory failure due to
,overdose of pain medication and an aspiration pneumonia. What is the principal
diagnosis?
A. Acute respiratory failure
B. Aspiration pneumonia
C. Poisoning
D. Adverse effect of medication
D. All of the conditions should be coded - CORRECT ANSWER -A patient is
admitted with pneumonia, stage 1 chronic renal failure, chronic anemia, and
COPD, While hospitalized the patient receives IV antibiotics, inhalers, oxygen,
IV fluids at 50mL/hr, and iron tablets. Keeping the guidelines for coding of
secondary diagnoses in mind, which condition should be coded?
A. Pneumonia only
B. Pneumonia and COPD only
C. Pneumonia, COPD, and anemia
D. All of the conditions should be coded
D. Fractured ulna - CORRECT ANSWER -Which of the following is an
example of a hospital-acquired condition?
A. Fat embolism
B. IV phlebitis
C. Pneumonia
D. Fractured ulna
C. A diagnosis that is listed as possible in the history and physical - CORRECT
ANSWER -Which of the following is an example of documentation that would
meet the present on admission criteria for coding?
, A. A diagnosis that is indicated in the history and physical and ruled out in the
discharge summary
B. A diagnosis found in a previous medical record
C. A diagnosis that is listed as possible in the history and physical
D. An acute condition identified on the third day of admission
A. Colon cancer - CORRECT ANSWER -A patient is admitted with
abdominal pain and the history and physical indicated a diagnosis of probable
colon cancer. On day two, the physician documents acute renal failure in the
progress notes and the patient receives IV fluids. The discharge summary lists
possible metastatic colon cancer and acute renal failure. The principal diagnosis
would be:
A. Colon cancer
B. Acute renal failure
C. Abdominal pain
D. Metastatic neoplasm of the colon
D. 1,2, and 3
1. Include identification of the patient's SOI
2. Identify conditions that are present on admission
3. Support medical necessity - CORRECT ANSWER -Accurate
documentation should:
1. Include identification of the patient's SOI
2. Identify conditions that are present on admission
3. Support medical necessity
