作為IT認證的一項重要考試，ACDIS CCDS認證資格可以給你帶來巨大的好處，所有請把握這次可以成功的機會。為了能順利通過考試，持有完全版的ACDIS CCDS題庫資料是必要的，你就能輕松通過想要的認證考試。此外，VCESoft提供的所有考古題都是最新的，其中PDF版本的CCDS題庫支持打打印，方便攜帶，現在就來添加我們最新的CCDS考古題，了解更多的考試資訊吧！
| Section | Weight | Objectives |
|---|---|---|
| Topic 1: Anatomy and physiology, pathophysiology, pharmacology, and medical terminology | 19.17% | - Anatomy, physiology, pathophysiology, pharmacology, and terminology - Clinical conditions and clinical indicators |
| Topic 2: Healthcare facility CDI program analysis | 8.33% | - Data analysis, forecasting, and performance measurement - CDI productivity, provider response, CMI, and program metrics |
| Topic 3: Impact of reportable diagnoses on quality of care | 8.33% | - Mortality, severity of illness, and risk of mortality - Quality metrics, reporting programs, and financial impact |
| Topic 4: Professionalism, ethics, and compliance | 9.17% | - Confidentiality, DRG compliance, and ethical CDI practices - Query compliance, DRG creep, and audit risks |
| Topic 5: Healthcare regulations, reimbursement, and documentation requirements related to the IPPS | 12.5% | - CC/MCC, CMI, Medicare contractors, and compliance - IPPS, MS-DRGs, reimbursement, and medical necessity |
| Topic 6: Medical record documentation | 19.17% | - Documentation clarification and compliant physician queries - Documentation requirements and diagnosis or procedure code assignment |
| Topic 7: Communication skills | 9.17% | - Physician education and effective communication - CDI and coding roles and interdisciplinary collaboration |
| Topic 8: Official Guidelines for Coding and Reporting | 14.17% | - Coding guidelines, AHA Coding Clinic, HACs, and POA indicators - Principal and secondary diagnosis assignment |
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問題 #29
A physician documents "postoperative urinary retention" after surgery. The patient required temporary catheterization, but the surgeon indicates that urinary retention is a common expected consequence of anesthesia in this case. What should the CDI specialist do before treating the condition as a postoperative complication?
答案：D
解題說明：
The CDI specialist should clarify whether the urinary retention represents an actual postoperative complication or an expected consequence of surgery/anesthesia.
ICD-10-CM does not classify every condition that occurs after medical or surgical care as a complication.
Provider documentation must establish the appropriate relationship when required, and the condition should represent more than an expected physiologic consequence.
Temporary urinary retention can occur after anesthesia, opioid administration, pelvic surgery, or immobilization. Its appearance following surgery therefore does not automatically establish a complication of care.
The query should objectively present the postoperative urinary retention, catheterization, duration, treatment, and any surgeon or anesthesia documentation indicating whether the event was expected. The provider can then characterize the condition appropriately.
Automatically assigning a device-related complication would introduce another unsupported causal relationship. CDI also cannot delete the documented condition simply because it may be expected.
This distinction is important because complication codes can influence MS-DRG assignment, quality reporting, patient-safety analyses, and public performance information. Accurate characterization is therefore essential.
CCDS Reference Topics: Complications of care; postoperative urinary retention; cause-and-effect relationship; clinical clarification.
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問題 #30
A CDI team identifies that orthopedic surgeons frequently document "postoperative anemia" without specifying whether blood loss is acute, expected, chronic, or clinically insignificant. What is the BEST educational strategy?
答案：B
解題說明：
The strongest educational approach is targeted specialty-specific education using the surgeons' own documentation trends and realistic clinical examples. This addresses the recurring documentation problem while remaining clinically relevant to the audience.
Orthopedic surgeons do not need to become coding specialists. Education should instead explain which clinical distinctions matter-for example, whether anemia represents expected postoperative change, acute blood loss anemia, chronic anemia, or another diagnosis-and why accurate terminology improves the medical record.
Providing a long code list is unlikely to improve physician documentation behavior. Instructing surgeons to document acute blood loss anemia whenever hemoglobin decreases would be clinically inappropriate and could produce unsupported diagnoses. A postoperative hemoglobin decline may reflect hemodilution, expected surgical blood loss, chronic anemia, or other factors.
Stopping queries would leave meaningful ambiguities unresolved.
ACDIS/AHIMA query guidance emphasizes documentation accuracy and provider independence rather than reimbursement-focused diagnosis selection.
Successful physician education should be concise, clinically oriented, supported by service-line data, and reinforced when subsequent query trends demonstrate persistent problems.
CCDS Reference Topics: Physician education; communication; postoperative anemia; query trends; provider engagement.
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問題 #31
A patient undergoes outpatient surgery at 9:00 AM. At 1:00 PM, while still in outpatient status, the patient develops an acute complication. The physician writes an inpatient admission order at 4:00 PM. The complication remains present at that time. How is the condition generally treated for POA purposes?
答案：B
解題說明：
POA status is determined in relation to the time of inpatient admission, not the patient's physical arrival at the hospital. Therefore, a condition that develops during outpatient surgery, emergency-department care, or observation and remains present when the inpatient admission order occurs is generally considered present on admission for inpatient POA reporting.
This concept can be counterintuitive because the condition technically developed after the patient entered the hospital building. However, CMS's POA framework distinguishes outpatient care from the subsequent inpatient admission.
The fact that the condition is a complication does not automatically make it POA = N. POA status and classification as a complication are separate concepts.
A "U" indicator signifies insufficient documentation to determine whether the condition was present at admission; it should not be selected merely because a condition arose during outpatient care before admission.
CDI specialists frequently need to establish precise clinical timelines involving emergency services, observation, procedures, admission orders, and onset of complications. Clear timing supports accurate POA assignment and is especially important when diagnoses intersect with CMS HAC payment logic.
The CCDS framework specifically expects knowledge of POA and inpatient reimbursement regulations.
CCDS Reference Topics: POA; outpatient-to-inpatient transition; admission timing; HAC policy.
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問題 #32
A patient with dysphagia after a recent stroke develops fever, hypoxia, and a right lower-lobe infiltrate. The physician documents "pneumonia." Speech therapy documents repeated aspiration with oral intake. What is the MOST appropriate CDI action?
答案：A
解題說明：
The record presents a legitimate opportunity to clarify the type or etiology of pneumonia, particularly whether aspiration contributed to the pulmonary infection. Dysphagia following stroke, documented aspiration during oral intake, fever, hypoxia, and a dependent-lobe infiltrate form a clinically relevant pattern.
However, the CDI specialist cannot independently convert unspecified pneumonia into aspiration pneumonia.
Likewise, the speech-language pathologist can provide valuable clinical evidence regarding swallowing dysfunction and aspiration risk, but that documentation does not independently establish the medical diagnosis of aspiration pneumonia for coding purposes.
A compliant query should objectively present the pertinent indicators and allow the provider to identify aspiration pneumonia, another pneumonia type, pneumonitis, another condition, or inability to determine.
Automatically assigning both bacterial and aspiration pneumonia would also be inappropriate because neither bacterial etiology nor a separate second pneumonia diagnosis has been established.
The current ACDIS/AHIMA guidance emphasizes that queries should arise from the clinical record and preserve the provider's independent judgment rather than directing a preferred diagnosis.
CCDS Reference Topics: Pneumonia specificity; aspiration; dysphagia; interdisciplinary documentation; compliant query development.
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問題 #33
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?
答案：B
解題說明：
The phrase "post-op ileus" establishes that the ileus occurred after surgery, but it does not necessarily establish that the ileus represents a reportable surgical complication rather than an expected transient consequence of abdominal surgery. The relationship and clinical significance therefore require clarification.
ICD-10-CM guidance on complications of care states that not every condition occurring during or following surgery is automatically classified as a complication. Code assignment depends on provider documentation establishing the relationship between the condition and the care or procedure, and the documentation must support clinical significance. When that relationship is unclear, the provider should be queried.
Assigning a complication code immediately would therefore be premature. Likewise, simply coding postoperative ileus without resolving whether it represents expected postoperative physiology or a clinically significant complication could misrepresent the episode.
Escalation to a physician advisor or CDI manager is unnecessary as the first action because this is a standard documentation-clarification issue that can be addressed directly through a compliant provider query.
CCDS Reference Topics: Official Guidelines-complications of care; medical record documentation; compliant provider clarification.
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問題 #34
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