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 CKD stage corresponds to a GFR of 15–29 mL/min/1.73m²? → Stage 4
3. 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
4. Which of the following documentation examples provides the highest level of specificity for coding and MS-DRG impact? → Severe protein-calorie malnutrition
5. 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.
6. When is a 'Yes/No' query format considered non-compliant? → When asking the physician to establish a new diagnosis based on clinical indicators.
7. 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
8. Which ICD-10-CM code is used when a physician documents 'cachexia' without specifying an underlying cause? → R64 - Cachexia
9. The Uniform Hospital Discharge Data Set (UHDDS) provides official definitions for which of the following? → Principal diagnosis and other diagnoses
10. 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
11. 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
12. 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)
13. Which coding system is used for coding durable medical equipment, prosthetics, orthotics, and supplies? → HCPCS Level II
14. Which OIG program provides annual guidance on high-risk healthcare compliance areas including CDI and coding? → OIG Work Plan and annual compliance program guidance
15. Under ICD-10-PCS guidelines, which procedure is defined as the 'principal procedure' for DRG grouping purposes? → The procedure most related to the principal diagnosis and most resource-intensive
16. A patient with type 2 diabetes mellitus is documented with CKD Stage 3b. What is the correct ICD-10-CM coding approach? → Assign E11.22 for diabetic chronic kidney disease plus N18.32 for the specific CKD stage
17. A hospitalist documents 'possible CHF exacerbation, probable pneumonia' in the discharge summary. How should the final codes reflect this? → Code both CHF exacerbation and pneumonia per the inpatient uncertain diagnosis guideline
18. A CDS identifies conflicting information in the medical record regarding the cause of a patient's anemia. What is the most appropriate action? → Initiate a physician query for clarification.
19. Which documented condition, if present alongside AKI, would most likely result in an MS-DRG upgrade reflecting greater patient resource intensity? → Acute kidney injury with tubular necrosis, classified as an MCC
20. Under ICD-10-PCS, which root operation describes surgically cutting a body part without draining fluids or removing tissue? → Division
21. Which CDI query approach is most appropriate when a patient presents with acute decompensated heart failure? → Query for the underlying cause of decompensation
22. What is the primary goal of data analysis in clinical documentation? → To ensure accurate coding and billing
23. Which of the following is a key component of effective healthcare documentation? → Detailed, accurate, and timely entries
24. Which of the following conditions is on the CMS list of Hospital-Acquired Conditions (HACs) that can lead to a payment reduction if not POA? → Falls and trauma (e.g., fracture) acquired during the stay
25. A patient with diabetes has a foot ulcer. What documentation elements must the CDI specialist verify for accurate code assignment? → Type of diabetes and the depth/severity of the ulcer
26. A discharge summary that conflicts with the body of the medical record should be handled in which of the following ways? → Query the physician to resolve the discrepancy before finalizing the coded record
27. What is required to code cardiogenic shock in ICD-10-CM? → Explicit physician documentation of cardiogenic shock
28. Which ICD-10-CM code is assigned for end-stage renal disease (ESRD) requiring renal replacement therapy? → N18.6
29. Under ICD-10-PCS, which of the seven characters defines the specific approach used for a procedure? → Character 5 (Approach)
30. Which statement BEST describes the relationship between Severity of Illness (SOI) and Risk of Mortality (ROM) scores in the APR-DRG system? → SOI measures resource use while ROM independently measures likelihood of death