Exam Code: CCDS
Exam Name: Certified Clinical Documentation Specialist
Updated: Sep 28, 2026
Q & A: 152 Questions and Answers
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A patient has chronic gastroesophageal reflux disease listed in the past medical history. During the current hospitalization for bacterial pneumonia, GERD receives no clinical evaluation, treatment, diagnostic testing, increased nursing monitoring, or effect on length of stay. Which statement is MOST accurate?
Correct Answer: A 🗳️
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A patient is admitted with right-sided weakness and aphasia. MRI confirms an acute left cerebral infarction.
Two days later, aphasia resolves but right-sided weakness remains. The physician's documentation continues to state "TIA." What should the CDI specialist do?
Correct Answer: C 🗳️
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Documentation indicates an excisional debridement was performed without further specification. The CDI specialist should query to clarify which of the following?
Correct Answer: D 🗳️
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A patient is admitted with a stage 2 sacral pressure ulcer. During the hospitalization, the ulcer progresses and is documented as stage 3 at the same site. How should the pressure ulcer be reported?
Correct Answer: C 🗳️
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During one month, a CDI department issued 400 queries. Providers responded to 360 of them. What was the provider query response rate?
Correct Answer: C 🗳️
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