100+ Free ACDIS CCDS Practice Questions

Explanation: The Uniform Hospital Discharge Data Set (UHDDS) defines the principal diagnosis as the condition established after study to be chiefly responsible for occasioning the admission of the patient to the hospital for care. 'After study' allows the diagnosis to be determined once workup is complete, not necessarily the admitting diagnosis.

Explanation: An MCC reflects a more severe condition requiring more resources than a CC, so it typically moves a case into a higher-weighted MS-DRG tier and yields greater reimbursement. Many MS-DRG families have three tiers: with MCC, with CC, and without CC/MCC.

Explanation: The POA indicator 'W' means clinically undetermined — the provider is unable to clinically determine whether the condition was present on admission. This reflects clinical ambiguity rather than a documentation gap. For HAC payment purposes, 'W' is treated like 'Y' (paid).

Explanation: A leading query is one that is not supported by the clinical elements in the record and/or directs a provider to a specific diagnosis or procedure. Compliant queries present clinical indicators and allow the provider to reach an independent conclusion without being steered to a desired answer.

Explanation: APR-DRGs assign each case to one of four SOI and four ROM subclasses: 1 (minor), 2 (moderate), 3 (major), and 4 (extreme). SOI reflects physiologic decompensation/organ loss of function while ROM reflects likelihood of dying; the two are scored independently.

Explanation: Commonly cited diagnostic thresholds for acute respiratory failure include a pO2 less than 60 mmHg (hypoxemic) and/or a pCO2 greater than 50 mmHg with pH below 7.35 (hypercapnic). The diagnosis should also be symptomatic and supported by the clinical picture, not ABG values alone.

Explanation: Sepsis-3 defines sepsis as life-threatening organ dysfunction caused by a dysregulated host response to infection, operationalized as an acute increase of 2 or more points in the SOFA score in the setting of suspected or confirmed infection. SIRS criteria are no longer part of the Sepsis-3 definition.

Explanation: A concurrent query is generated during the patient's stay, while the record is still open and care is ongoing. Concurrent queries are preferred because the provider has the patient in front of them and can document clarifications in real time, improving accuracy before coding and billing.

Explanation: The ICD-10-CM Official Guidelines for Coding and Reporting, approved by the four Cooperating Parties (AHA, AHIMA, CMS, NCHS), are the authoritative rules for diagnosis code assignment and sequencing. They accompany and complement the conventions and instructions in the classification itself.

Explanation: Under the HAC payment provision, certain conditions that are NOT present on admission (POA = N or U) will not be counted as a CC or MCC when grouping the case, removing the higher payment that condition would otherwise generate. This discourages payment for preventable conditions acquired in the hospital.