Certified Clinical Documentation Specialist (CCDS)
Certification Final Exam | Complete Test Bank with
100 Real Exam Questions & Detailed Verified Correct
Answers | Rated A+
Question 1
The CFO asks you to calculate the case-mix index (CMI) of the Medicare patients who were
discharged from your medical-surgical unit last week. He tells you the hospital's blended rate is
$5,000. You determine the following patients were discharged during that time period (relative
weights are fictitious):
DRG 280 (RW 1.8503) – 5 patients
DRG 64 (RW 1.8674) – 1 patient
DRG 193 (RW 1.4796) – 5 patients
DRG 207 (RW 5.2068) – 2 patients
DRG 871 (RW 1.9074) – 4 patients
DRG 101 (RW 0.7619) – 1 patient
DRG 177 (RW 2.0667) – 10 patients
DRG 313 (RW 0.5499) – 15 patients
The CMI is:
A. 1.9612
B. 0.3648
C. 1.5404
D. 15.690
Correct Answer: C
Rationale: CMI is calculated by summing the total relative weights (5×1.8503 + 1×1.8674 +
5×1.4796 + 2×5.2068 + 4×1.9074 + 1×0.7619 + 10×2.0667 + 15×0.5499 = 60.7771) and
dividing by total patients (5+1+5+2+4+1+10+15 = 43). 60.7771 ÷ 43 = 1.5404.
Question 2
A patient is admitted with weakness, dehydration, and AMS. The patient also has a history of
CKD stage 2 with a baseline creatinine of 1.6, CHF, HTN, and CABG. BUN is 32, creatinine is
2.4, and urinalysis is positive for white blood cells. Head CT is negative for acute changes. The
patient is started on IV fluids and antibiotics. Labs after 2 liters of fluid are BUN 28 and
creatinine 1.7. The physician documents the following impression list:
pg. 1
, • Dehydration with pre-renal azotemia
• UTI
• CKD
• AMS
Which of the following is an appropriate concurrent query?
A. Documentation indicates creatinine 2.4 on admission decreasing to 1.7 after 2 liters of fluid
administered. Please clarify the condition you are monitoring and treating related to creatinine.
Based upon presentation of altered mental status, are you also treating a CVA?
B. Please specify the reason for the IV fluids
C. Please specify the principal diagnosis
Correct Answer: A
Rationale: The query should address the acute kidney injury (creatinine improvement after
fluids suggests pre-renal azotemia) and clarify the altered mental status to rule out CVA.
Question 3
A patient is admitted with fever, shortness of breath, chest pain, and non-productive cough. Chest
x-ray confirms a pleural effusion. Which type of effusion is most probable for this patient?
A. Malignant
B. Transudative
C. Exudative
D. Serosanguinous
Correct Answer: C
Rationale: Fever, chest pain, and non-productive cough suggest an inflammatory process
(pneumonia, infection), which typically causes exudative effusion.
Question 4
An elderly patient with a history of CAD, GERD, and HTN is admitted with chest pain. Pain was
unrelieved with nitroglycerin at home. A GI cocktail is administered in the ED with relief.
Cardiac workup is negative, and the patient is scheduled for an EGD. The physician documents
atypical chest pain. A concurrent query:
A. Is not necessary to code GERD as the principal diagnosis
B. Would be needed to specify the cause of the chest pain
C. Would not be necessary as chest pain is the principal diagnosis
D. Would be needed to specify the type of GERD
pg. 2
,Correct Answer: B
Rationale: Since GI cocktail relieved the pain, GERD is likely the cause. A query should clarify
whether the chest pain was due to GERD for accurate principal diagnosis assignment.
Question 5
A patient is being treated with cefoxitin for pneumonia. What type of pneumonia is most likely
being treated?
A. Gram positive
B. Community acquired
C. Gram negative
D. Pneumococcal
Correct Answer: C
Rationale: Cefoxitin is a second-generation cephalosporin effective against gram-negative
organisms including anaerobes, often used for aspiration pneumonia.
Question 6
A patient is admitted with syncope. Typical considerations for the underlying cause of syncope
include:
A. Cardiac arrhythmia and fluid overload
B. CHF and renal failure
C. Diabetes, bradycardia, and dehydration
D. Obesity and colon cancer
Correct Answer: C
Rationale: Common causes of syncope include cardiac causes (bradycardia), metabolic causes
(diabetes), and hypovolemia (dehydration).
Question 7
When concurrently formulating a query to clarify whether a patient has a gastrointestinal
hemorrhage, it is important to assist the physician in understanding which of the following
coding rules?
A. Active bleeding does not need to be visualized in an endoscopy; the physician impression can
be documented and coded
B. Bleeding must be visualized in order to code an active bleed
C. A positive hemoccult is sufficient documentation to code GI hemorrhage
D. The EGD report will be used to code the location of the GI hemorrhage
pg. 3
, Correct Answer: A
Rationale: Clinical documentation (physician impression) is sufficient to code GI hemorrhage;
direct visualization is not required.
Question 8
A patient is admitted with cholelithiasis and is scheduled for a laparoscopic cholecystectomy.
When reviewing the operation report, the documentation specialist notes the words "dilation of
the sphincter of Oddi." This is important because it indicates:
A. Stones may have been left behind
B. A non-reimbursable procedure was performed
C. The procedure had to be performed via an incision and will lead to a different surgical MS-
DRG
D. A complication that will code as an MCC
Correct Answer: C
Rationale: Dilation of the sphincter of Oddi indicates a more invasive procedure (possibly open)
leading to a different surgical MS-DRG than a simple laparoscopic cholecystectomy.
Question 9
When a patient's admission includes a reimbursable surgical procedure, assignment of the final
MS-DRG will:
A. Always be in the same MDC as the principal medical diagnosis
B. Always include a comorbid condition (CC/MCC)
C. Depend on the patient's age
D. Be driven by the surgical hierarchy established by CMS
Correct Answer: D
Rationale: CMS surgical hierarchy determines that surgical DRGs take precedence over medical
DRGs when a reimbursable procedure is performed.
Question 10
A query has been pending on a case for three days, and the patient is scheduled for discharge
today. Which of the following is the most effective technique for obtaining a timely response?
A. Email the physician with the query information
B. Call the physician's department chair to report noncompliance
C. Let coding initiate a retrospective query
D. Try to meet face to face with the physician and discuss the query
pg. 4
Certification Final Exam | Complete Test Bank with
100 Real Exam Questions & Detailed Verified Correct
Answers | Rated A+
Question 1
The CFO asks you to calculate the case-mix index (CMI) of the Medicare patients who were
discharged from your medical-surgical unit last week. He tells you the hospital's blended rate is
$5,000. You determine the following patients were discharged during that time period (relative
weights are fictitious):
DRG 280 (RW 1.8503) – 5 patients
DRG 64 (RW 1.8674) – 1 patient
DRG 193 (RW 1.4796) – 5 patients
DRG 207 (RW 5.2068) – 2 patients
DRG 871 (RW 1.9074) – 4 patients
DRG 101 (RW 0.7619) – 1 patient
DRG 177 (RW 2.0667) – 10 patients
DRG 313 (RW 0.5499) – 15 patients
The CMI is:
A. 1.9612
B. 0.3648
C. 1.5404
D. 15.690
Correct Answer: C
Rationale: CMI is calculated by summing the total relative weights (5×1.8503 + 1×1.8674 +
5×1.4796 + 2×5.2068 + 4×1.9074 + 1×0.7619 + 10×2.0667 + 15×0.5499 = 60.7771) and
dividing by total patients (5+1+5+2+4+1+10+15 = 43). 60.7771 ÷ 43 = 1.5404.
Question 2
A patient is admitted with weakness, dehydration, and AMS. The patient also has a history of
CKD stage 2 with a baseline creatinine of 1.6, CHF, HTN, and CABG. BUN is 32, creatinine is
2.4, and urinalysis is positive for white blood cells. Head CT is negative for acute changes. The
patient is started on IV fluids and antibiotics. Labs after 2 liters of fluid are BUN 28 and
creatinine 1.7. The physician documents the following impression list:
pg. 1
, • Dehydration with pre-renal azotemia
• UTI
• CKD
• AMS
Which of the following is an appropriate concurrent query?
A. Documentation indicates creatinine 2.4 on admission decreasing to 1.7 after 2 liters of fluid
administered. Please clarify the condition you are monitoring and treating related to creatinine.
Based upon presentation of altered mental status, are you also treating a CVA?
B. Please specify the reason for the IV fluids
C. Please specify the principal diagnosis
Correct Answer: A
Rationale: The query should address the acute kidney injury (creatinine improvement after
fluids suggests pre-renal azotemia) and clarify the altered mental status to rule out CVA.
Question 3
A patient is admitted with fever, shortness of breath, chest pain, and non-productive cough. Chest
x-ray confirms a pleural effusion. Which type of effusion is most probable for this patient?
A. Malignant
B. Transudative
C. Exudative
D. Serosanguinous
Correct Answer: C
Rationale: Fever, chest pain, and non-productive cough suggest an inflammatory process
(pneumonia, infection), which typically causes exudative effusion.
Question 4
An elderly patient with a history of CAD, GERD, and HTN is admitted with chest pain. Pain was
unrelieved with nitroglycerin at home. A GI cocktail is administered in the ED with relief.
Cardiac workup is negative, and the patient is scheduled for an EGD. The physician documents
atypical chest pain. A concurrent query:
A. Is not necessary to code GERD as the principal diagnosis
B. Would be needed to specify the cause of the chest pain
C. Would not be necessary as chest pain is the principal diagnosis
D. Would be needed to specify the type of GERD
pg. 2
,Correct Answer: B
Rationale: Since GI cocktail relieved the pain, GERD is likely the cause. A query should clarify
whether the chest pain was due to GERD for accurate principal diagnosis assignment.
Question 5
A patient is being treated with cefoxitin for pneumonia. What type of pneumonia is most likely
being treated?
A. Gram positive
B. Community acquired
C. Gram negative
D. Pneumococcal
Correct Answer: C
Rationale: Cefoxitin is a second-generation cephalosporin effective against gram-negative
organisms including anaerobes, often used for aspiration pneumonia.
Question 6
A patient is admitted with syncope. Typical considerations for the underlying cause of syncope
include:
A. Cardiac arrhythmia and fluid overload
B. CHF and renal failure
C. Diabetes, bradycardia, and dehydration
D. Obesity and colon cancer
Correct Answer: C
Rationale: Common causes of syncope include cardiac causes (bradycardia), metabolic causes
(diabetes), and hypovolemia (dehydration).
Question 7
When concurrently formulating a query to clarify whether a patient has a gastrointestinal
hemorrhage, it is important to assist the physician in understanding which of the following
coding rules?
A. Active bleeding does not need to be visualized in an endoscopy; the physician impression can
be documented and coded
B. Bleeding must be visualized in order to code an active bleed
C. A positive hemoccult is sufficient documentation to code GI hemorrhage
D. The EGD report will be used to code the location of the GI hemorrhage
pg. 3
, Correct Answer: A
Rationale: Clinical documentation (physician impression) is sufficient to code GI hemorrhage;
direct visualization is not required.
Question 8
A patient is admitted with cholelithiasis and is scheduled for a laparoscopic cholecystectomy.
When reviewing the operation report, the documentation specialist notes the words "dilation of
the sphincter of Oddi." This is important because it indicates:
A. Stones may have been left behind
B. A non-reimbursable procedure was performed
C. The procedure had to be performed via an incision and will lead to a different surgical MS-
DRG
D. A complication that will code as an MCC
Correct Answer: C
Rationale: Dilation of the sphincter of Oddi indicates a more invasive procedure (possibly open)
leading to a different surgical MS-DRG than a simple laparoscopic cholecystectomy.
Question 9
When a patient's admission includes a reimbursable surgical procedure, assignment of the final
MS-DRG will:
A. Always be in the same MDC as the principal medical diagnosis
B. Always include a comorbid condition (CC/MCC)
C. Depend on the patient's age
D. Be driven by the surgical hierarchy established by CMS
Correct Answer: D
Rationale: CMS surgical hierarchy determines that surgical DRGs take precedence over medical
DRGs when a reimbursable procedure is performed.
Question 10
A query has been pending on a case for three days, and the patient is scheduled for discharge
today. Which of the following is the most effective technique for obtaining a timely response?
A. Email the physician with the query information
B. Call the physician's department chair to report noncompliance
C. Let coding initiate a retrospective query
D. Try to meet face to face with the physician and discuss the query
pg. 4
