CCDS Cheat Sheet 2026

The 30 highest-yield CCDS facts, distilled from real exam questions. Print it, save it as a PDF, or study it here — free, no sign-up.

1. What is the role of a Clinical Documentation Specialist (CDS) in relation to clinical coding? → To ensure that clinical documentation supports accurate coding and billing
2. Which cardiac condition, if documented as 'possible' or 'probable' at discharge in an inpatient setting, may be coded under UHDDS guidelines? → Possible acute pericarditis documented at discharge on an inpatient record
3. In the context of chronic illness-related malnutrition, which weight loss percentage over 6 months meets ASPEN criteria for SEVERE malnutrition? → Greater than 20% weight loss over 6 months
4. In a clinical data quality audit, a CDS specialist finds that 15% of records lack a principal diagnosis. This metric is best classified as a measure of: → Data completeness
5. A hospital receives a Targeted Probe and Educate (TPE) review notice from its MAC. What is the primary purpose of this review process? → To educate providers on proper billing and reduce error rates before enforcement
6. Which CKD stage corresponds to a GFR of 15–29 mL/min/1.73m²? → Stage 4
7. A CDIS reviews a record where the physician documents 'MRSA bacteremia.' Which ICD-10-CM coding approach is correct? → Code B95.62 as an additional code to A41.02
8. A patient loses 5% of body weight in 1 month due to inadequate oral intake post-surgery. Per ASPEN criteria, this weight loss severity is classified as: → Moderate malnutrition
9. Which clinical indicator would most support a CDI query for acute kidney injury in a hospitalized patient? → Serum creatinine rise of 0.4 mg/dL above baseline within 36 hours
10. Which of the following documentation examples provides the highest level of specificity for coding and MS-DRG impact? → Severe protein-calorie malnutrition
11. What is the primary reason the designation of a procedure as 'OR' versus 'Non-OR' is critical for a CDS to recognize? → It is the primary determinant for assigning a case to a surgical MS-DRG.
12. Which CDI strategy is MOST effective when implementing a new CDI program in a facility with low physician engagement? → Begin with a physician champion and pilot the program in a high-volume service line
13. Under Sepsis-3, which statement best describes the role of SIRS criteria in diagnosing sepsis? → SIRS criteria were eliminated from the Sepsis-3 definition
14. When is a 'Yes/No' query format considered non-compliant? → When asking the physician to establish a new diagnosis based on clinical indicators.
15. What is the correct ICD-10-CM coding for a patient with chronic systolic heart failure admitted for acute exacerbation? → Code the acute-on-chronic systolic heart failure with the appropriate combined code
16. Which ICD-10-CM code is used when a physician documents 'cachexia' without specifying an underlying cause? → R64 - Cachexia
17. According to ICD-10-CM guidelines, how should 'probable' diagnoses be coded in the outpatient/physician office setting? → Code only the signs and symptoms, not the probable diagnosis
18. Under the Hospital-Acquired Condition Reduction Program (HACRP), what happens to hospitals in the worst-performing quartile? → They receive a 1% reduction in Medicare inpatient payments
19. The Uniform Hospital Discharge Data Set (UHDDS) provides official definitions for which of the following? → Principal diagnosis and other diagnoses
20. When a STEMI is treated with percutaneous coronary intervention (PCI), what documentation must the CDI specialist verify for complete procedure coding? → Both the specific coronary artery involved and the stent type used
21. Under ICD-10-CM guidelines, if a patient is admitted with pneumonia that subsequently leads to sepsis during the hospitalization, how is the case coded? → Pneumonia is sequenced as principal diagnosis; sepsis is a secondary diagnosis
22. Which of the following conditions is NOT included in the CMS list of Hospital-Acquired Conditions subject to the HAC payment provision? → Community-acquired Clostridioides difficile infection
23. When tracking CDI program performance, which trend would indicate a PROBLEM with query compliance? → A consistently high rate of 'unable to determine' physician responses to queries
24. A patient is documented with 'ventilator-associated pneumonia (VAP).' Which additional ICD-10-CM code must accompany the VAP code J95.851? → A code for the causative organism
25. Which statistical measure is BEST used to identify outlier cases where actual LOS far exceeds the expected LOS for the assigned DRG? → Standard deviation from the Geometric Mean Length of Stay (GMLOS)
26. Which coding system is used for coding durable medical equipment, prosthetics, orthotics, and supplies? → HCPCS Level II
27. Under the Uniform Hospital Discharge Data Set (UHDDS), what defines the principal diagnosis? → The condition established after study to be chiefly responsible for the admission
28. Which OIG program provides annual guidance on high-risk healthcare compliance areas including CDI and coding? → OIG Work Plan and annual compliance program guidance
29. ICD-10-CM guideline Section I.C.19 covers coding for injuries. When multiple injuries are present, what guides principal diagnosis selection? → The most serious injury, as determined by the provider, guides sequencing
30. Which of the following statements about query timing is MOST accurate under compliant query practices? → Queries may be issued concurrently during the encounter or retrospectively after discharge