AAPC CDEI Certification Sample Questions

The AAPC Certified Documentation Expert Inpatient Certification Sample Question Set on this page is designed to familiarize you with the actual AAPC CDEI exam format and question types. These sample questions help you understand how questions are structured and what to expect on test day. While they provide a useful starting point, they represent only a limited preview of the real exam experience.

These sample questions are intended for evaluation and familiarization only. To understand exam style, pacing, and reasoning patterns more clearly, we recommend trying our online sample practice environment. If you are preparing for the AAPC Certified Documentation Expert Inpatient (CDEI) and want to assess your readiness more rigorously, structured, timed, scenario-based practice is recommended. This approach aligns with the cognitive demands and professional expectations typically associated with clinical documentation improvement professionals, inpatient coders, coding auditors and related roles working in settings such as hospitals, inpatient facilities, health systems and related settings.

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The demo introduces core concepts, while full-length premium simulations provide deeper, scenario-based coverage that more closely reflects the actual cognitive demands of the AAPC Certified Documentation Expert Inpatient exam, particularly in areas such as inpatient documentation review, ICD-10-CM and ICD-10-PCS guideline application, provider query and CDI compliance. You can use these sample questions as a starting point, then progress to the AAPC CDEI Certification Practice Exam for stronger readiness. Our premium simulations are designed to mirror real exam conditions, helping you refine reasoning, pacing, and decision-making before your official exam attempt.

AAPC CDEI Sample Questions:

01. A CT scan report states “acute pulmonary embolism in the right lower lobe pulmonary artery.” The provider’s progress notes state “shortness of breath, awaiting CT results,” and the discharge summary lists “dyspnea.” The patient received heparin infusion and was discharged on anticoagulation.
What is the best CDI action?
a) Report dyspnea only because treatment data cannot support CDI review
b) Query the provider to confirm whether acute pulmonary embolism was diagnosed and treated
c) Code acute pulmonary embolism directly from the CT report without provider documentation
d) Ignore the CT report because radiology findings are not clinical indicators

02. A patient develops bleeding after a colonoscopy with polypectomy performed during the same admission. The gastroenterologist documents “post-polypectomy bleeding requiring repeat colonoscopy with cautery.” The discharge summary states “lower GI bleeding.” The coder asks whether the bleeding can be reported as a procedural complication.
What is the best CDI response?
a) Report only lower GI bleeding because complication coding is prohibited in inpatient records
b) Do not report bleeding because all post-procedure bleeding is expected and included
c) Clarify whether the provider considers the bleeding a complication of the polypectomy
d) Code a complication automatically because bleeding occurred after a procedure

03. A patient is admitted with fever, productive cough, hypoxia, and right lower lobe infiltrate. The provider documents “pneumonia.” Sputum culture later grows Pseudomonas aeruginosa, and antibiotics are changed from ceftriaxone to cefepime. The discharge summary still states only “pneumonia.”
What is the most appropriate CDI action?
a) Query the provider to clarify whether the pneumonia is due to Pseudomonas aeruginosa
b) Code Pseudomonas pneumonia directly because the sputum culture is positive
c) Report unspecified pneumonia because cultures are never relevant to CDI review
d) Replace pneumonia with acute bronchitis because the patient had a productive cough

04. A patient with alcoholic cirrhosis is admitted with abdominal distention, sodium 126 mEq/L, and worsening renal function. Paracentesis removes 5 liters of ascitic fluid, and the provider documents “decompensated alcoholic cirrhosis with ascites.” The discharge summary lists only “cirrhosis.”
Which CDI clarification is most useful?
a) Remove ascites because paracentesis makes it a resolved symptom
b) Code only abdominal distention because the discharge summary does not mention ascites
c) Query for viral hepatitis because all cirrhosis admissions require it
d) Clarify whether ascites and decompensation should be included in the final diagnoses

05. A pregnant patient at 20 weeks’ gestation is admitted for acute appendicitis and undergoes appendectomy. The provider documents “acute appendicitis complicating pregnancy.” Fetal monitoring is performed, and obstetrics follows the patient during the admission.
Which coding principle is most relevant?
a) Pregnancy complication coding is supported because the provider links appendicitis as complicating pregnancy
b) Appendicitis should be coded as unrelated because abdominal surgery is never pregnancy-related
c) Pregnancy should be ignored because the admission was managed by surgery
d) Only weeks of gestation should be coded because the appendicitis is not reportable

06. An inpatient is admitted for acute cholecystitis. The nutrition assessment documents BMI 42. The provider documents “morbid obesity complicating perioperative management,” and anesthesia uses additional positioning support and airway precautions during laparoscopic cholecystectomy.
Which documentation principle is most accurate?
a) Morbid obesity may be reportable when provider documented and clinically relevant, with BMI captured from appropriate documentation
b) BMI should be reported only when it is documented in the discharge summary by the surgeon
c) BMI alone is sufficient to code morbid obesity without provider documentation
d) Morbid obesity should be ignored because the admission was for acute cholecystitis

07. During pre-bill review, coding identifies “acute respiratory failure” as an MCC. CDI validation review shows the patient had no respiratory distress, no oxygen requirement, no abnormal blood gas, and the provider later states the phrase was copied forward from a prior admission and not current.
What is the most appropriate action?
a) Replace it with chronic respiratory failure without clinical support
b) Remove or correct the unsupported diagnosis through the appropriate coding and documentation process
c) Ask the provider to keep the diagnosis because removing it lowers reimbursement
d) Keep the MCC because it was present in the original discharge summary

08. The attending documents “acute systolic heart failure,” while the cardiology consultant documents “chronic systolic heart failure without acute exacerbation.” The patient received one dose of IV furosemide in the emergency department and was then restarted on home oral diuretics. The discharge summary lists “systolic heart failure.”
Which query approach is most appropriate?
a) Code acute systolic heart failure because attending documentation always overrides cardiology
b) Query for acute heart failure only because it has greater severity impact
c) Code chronic systolic heart failure because consultant documentation always overrides attending
d) Ask the provider to clarify the acuity of systolic heart failure based on the conflicting documentation and treatment course

09. An operative note states: “The surgeon performed a percutaneous mechanical thrombectomy of the right femoral artery through a needle puncture. No open incision was made.” The procedure is being coded in ICD-10-PCS.
Which approach value concept is most appropriate?
a) Open
b) Percutaneous
c) Via natural or artificial opening
d) External

10. A CDI department stores provider query responses outside the EHR in a shared spreadsheet. The coding team uses those responses to assign diagnoses, but the responses are not retained in the legal medical record or in an approved business record repository.
What is the strongest CDI compliance concern?
a) Query responses do not need retention if the coder remembers the provider’s answer
b) Query responses should be deleted after billing to reduce audit exposure
c) Query responses used for coding should be retained according to organizational policy and audit standards
d) Query responses are valid only when stored in a spreadsheet rather than the EHR

Answers:

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Note: These sample questions are not official exam questions and are intended only for familiarization and study purposes. If you find any typos or data entry errors in these AAPC Certified Documentation Expert Inpatient (CDEI) sample questions, please let us know by emailing us at feedback@medicoexam.com