Exam Code: CCDS
Exam Name: Certified Clinical Documentation Specialist
Updated: Oct 01, 2026
Q & A: 152 Questions and Answers
CCDS Free Demo download
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A patient with known heart failure presents with severe dyspnea, orthopnea, bilateral crackles, pulmonary edema, and lower-extremity edema. Echocardiography shows an ejection fraction of 28%. IV loop diuretics are administered. Which clarification is MOST clinically supported?
Correct Answer: C 🗳️
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A patient is admitted with TIA, right-sided weakness, and slurred speech. The physician's physical examination notes that the patient's right-sided weakness continues, but the slurred speech has resolved. A CT scan of the brain reveals a new hypodense area. The most specific diagnosis to query is acute:
Correct Answer: B 🗳️
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What type of query is needed to compliantly address a scenario in which clinical indicators of a diagnosis exist, but for which no diagnosis has been documented in the medical record?
Correct Answer: B 🗳️
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Based on the AHIMA/ACDIS Practice Brief Guidelines for Achieving a Compliant Query Practice, a leading query is one that:
Correct Answer: A 🗳️
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A patient with cirrhosis presents with confusion and asterixis. Ammonia is elevated and the patient improves after lactulose administration. The physician documents "altered mental status due to liver disease." Which clarification would provide the MOST clinically specific documentation?
Correct Answer: B 🗳️
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