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Last Updated: Nov 13, 2026
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ACDIS CCDS Exam Syllabus Topics:
| Section | Weight | Objectives |
|---|---|---|
| Topic 1: Anatomy and physiology, pathophysiology, pharmacology, and medical terminology | 19.17% | - Clinical indicators and query opportunities by Major Diagnostic Category - Diseases and disorders of the kidney and urinary tract - Diagnostic tests as clinical indicators - Diseases and disorders of the blood and blood-forming organs and immunological disorders - Alcohol/drug use and alcohol/drug-induced organic brain disorders - HIV infections - Diseases and disorders of the circulatory system - Pharmaceuticals and disease processes - Diseases and disorders of the skin, subcutaneous tissue, and breast - Endocrine, nutritional, and metabolic diseases and disorders - Diseases and disorders of the respiratory system - Standard medical abbreviations - Myeloproliferative diseases and disorders and poorly differentiated neoplasms - Infectious and parasitic diseases - Medications as clinical indicators - Diseases and disorders of the musculoskeletal system - Diseases and disorders of the digestive system - Mental diseases and disorders - Diseases and disorders of the nervous system - Injuries, poisonings, and toxic effects of drugs - Diseases and disorders of the hepatobiliary system |
| Topic 2: Healthcare facility CDI program analysis | 8.33% | - Publicly reported data - Severity of illness and risk of mortality - High-frequency DRGs - Hospital-specific financial data - Hospital Value-Based Purchasing measures - CC/MCC capture - Tracking and trending physician, department, and hospital performance - Patient Safety Indicators - Provider response rates - PEPPER data - Basic computer and software application skills - CDI program forecasting - Case mix index (CMI) - CDI specialist productivity metrics - Physician performance measurement |
| Topic 3: Communication skills | 9.17% | - Educational presentations for healthcare departments and administration - Reconciling CDI working DRGs with final coded DRGs - Physician education forms and tools - Roles and responsibilities of coders working with CDI departments - Roles and responsibilities of CDI specialists - Verbal versus written physician communication - Effective and non-confrontational physician communication |
| Topic 4: Professionalism, ethics, and compliance | 9.17% | - Potential DRG creep - Compliance risks indicated by PEPPER - DRG compliance initiatives - Leading queries - CDI department goals beyond reimbursement - Medical record confidentiality |
| Topic 5: Impact of reportable diagnoses on quality of care | 8.33% | - Hospital-Acquired Condition Reduction Program - Quality data from record abstraction and claims data - Mortality reviews and observed/expected ratios - 30-day mortality measures - Patient Safety Indicators - Hospital Value-Based Purchasing - Hospital Inpatient Quality Reporting Program - CDI impact on Hospital Value-Based Purchasing - Healthcare-associated infections and complication codes - Documentation and code assignment impact on mortality index - Coded data elements affecting Patient Safety Indicators - Hospital Readmissions Reduction Program |
| Topic 6: Official Guidelines for Coding and Reporting | 14.17% | - AHA Coding Clinic - Official Guidelines for Coding and Reporting updates - Present on admission indicators - Hospital-acquired conditions - Discharge dispositions and transfers - Principal diagnosis assignment - Secondary diagnosis assignment - Working DRG assignment for multiple diagnoses - Coding guidelines for principal diagnosis selection |
| Topic 7: Medical record documentation | 19.17% | - ACDIS/AHIMA Guidelines for Achieving a Compliant Query Practice - Provider role and diagnosis code assignment - When a physician query is warranted - Documentation requiring clarification - Types of physician queries - Physician query formats - Situations in which queries are not appropriate - Compliant and noncompliant queries - Translating clinical indicators into compliant queries - Addressing diagnoses without clinical support - Health record elements used for diagnosis and procedure code assignment - Clinical indicators |
| Topic 8: Healthcare regulations, reimbursement, and documentation requirements related to the IPPS | 12.5% | - IPPS and its updates and revisions - Principal diagnosis and medical necessity - Medicare contractors and their impact on CDI - Documentation and medical necessity of setting - Major complication/comorbidity (MCC) - Medicare Severity Diagnosis Related Groups (MS-DRGs) - Complication/comorbidity (CC) - Inpatient admission criteria and CMS Two-Midnight Rule - Coding and billing practices vulnerable to denial - Case mix index (CMI) - Documentation impact on IPPS reimbursement - Medical staff and clinical staff documentation responsibilities |
ACDIS Certified Clinical Documentation Specialist Sample Questions:
After a month of intermittent antibiotic use, the patient is admitted. An infectious-control physician documents a diagnosis of Clostridium difficile in the inpatient medical record. Which domain of the MOST current Hospital Value-Based Purchasing program would this diagnosis impact?
- A. Safety outcome
- B. PSI 90 data
- C. Clinical care
- D. Hospital-acquired infection
Correct Answer: A 🗳️
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Which pressure-ulcer category is specifically included in the traditional CMS HAC payment policy when the condition is not present on admission?
- A. Healed pressure ulcers only
- B. Stage 1 and stage 2 pressure ulcers
- C. All pressure injuries regardless of stage
- D. Stage 3 and stage 4 pressure ulcers
Correct Answer: D 🗳️
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A patient who underwent abdominal surgery one week ago is readmitted specifically for treatment of a postoperative wound infection documented by the surgeon as a complication of the procedure. Which condition should generally be considered for principal diagnosis selection?
- A. Fever
- B. Abdominal pain
- C. The original condition that required surgery
- D. The postoperative wound infection/complication
Correct Answer: D 🗳️
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A physician documents obesity. A registered dietitian records a BMI of 38.4 kg/m². Which statement is MOST accurate?
- A. The BMI may be obtained from the dietitian's documentation when the associated diagnosis is appropriately documented
- B. The BMI alone allows the coder to diagnose obesity
- C. The BMI cannot be used because only physicians may document BMI
- D. BMI should never be reported during an inpatient admission
Correct Answer: A 🗳️
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The table below shows physician performance:
Which of the following physicians will have the most favorable mortality rate on a public website, such as Healthgrades.com?
- A. 1
- B. 3
- C. 2
- D. 4
Correct Answer: D 🗳️
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