ACDIS CCDS case studies
ACDIS CCDS · Put your knowledge to work in context.
The Certified Clinical Documentation Specialist (CCDS) credential is a professional certification offered by ACDIS for clinical documentation integrity (CDI) professionals. ACDIS describes clinical documentation specialists as practitioners who draw on a wide range of specialized disciplines - anatomy and physiology, pathophysiology, and pharmacology; official medical coding guidelines together with CMS and private payer regulations related to the Inpatient Prospective Payment System; the ability to analyze and interpret medical record documentation and formulate appropriate physician queries; and the ability to benchmark and analyze clinical documentation program performance. The ACDIS CCDS case studies are 5 cases and about 3,853 words.
1BiPAP, ABGs, and a Signed Discharge Summary: Capturing Acute Respiratory Failure Before the Claim Drops
A 78-year-old man with COPD is admitted through the ED with two days of worsening dyspnea and purulent sputum. Vitals: respiratory rate 32/min, SpO2 84% on room air.
722 words, about 4 min2Creatinine Rise on Vancomycin Plus Pip-Tazo: Query Type, Present-on-Admission Status, and the Adverse-Event Question
A 69-year-old woman is admitted with urosepsis after two days of dysuria and fever. Empiric therapy is vancomycin plus piperacillin-tazobactam.
718 words, about 4 min3'Probable SBP' Meets a Consultant Who Disagrees: The Inpatient Uncertain-Diagnosis Rule and the Attending of Record
A 55-year-old man with alcohol-related cirrhosis is admitted with fever, abdominal pain, and tense ascites. Diagnostic paracentesis yields 480 PMN cells/mm3; ascitic culture is negative at five days.
760 words, about 4 min4Condition Code 44, a Verbal Agreement, and a Case Manager Asking the CDI to 'Make It Work'
A 74-year-old Medicare fee-for-service beneficiary is admitted as an inpatient for syncope. The ED note says 'admit for 23-hour observation'; the hospitalist writes an inpatient order.
845 words, about 4 min5A Dashboard That Looks Too Good: Query Metrics, a Leading Sepsis Query, and What to Tell the Board
A CDI specialist joins a 340-bed community hospital. Last quarter's dashboard shows 612 queries across 2,780 discharges (a 22% query rate), a 98% physician response rate, a 96% agreement rate, a 41% DRG change rate, and case-mix index growth from 1.62 to 1.74 in twelve months.
808 words, about 4 min