CDIP Practice Exam 1
CDIP Practice Exam 1
1. Assign code(s) for the following diagnosis: Congestive heart failure due to
hypertension.
I10 Essential (primary) hypertension
I11.9 Hypertensive heart disease without heart failure
I11.0 Hypertensive heart disease with heart failure
I50.9 Heart failure, unspecified
I50.1 Left ventricular failure
I50.20 Unspecified systolic (congestive) heart failure
I50.21 Acute systolic (congestive) heart failure
I50.22 Chronic systolic (congestive) heart failure
I50.23 Acute on chronic systolic (congestive) heart failure
a.I10, I50.9
b.I11.0
c.I50.23, I10
d.I11.0, I50.9: d Heart conditions are assigned a combination code when a causal
relationship is stated (due to hypertension) or implied (hypertensive). Use an ad-
ditional code to identify the type of heart failure in those patients with heart failure
(ICD-10-CM Official Guidelines for Coding and Reporting 2016b, 41).
2. Assign the best answer to complete the following sentence. The CPT codes
for treatment of fractures:
a.Use the terminology "manipulation" rather than "reduction" of fracture
b.Include internal fixation in all codes
c.Do not include application of cast
d.Do not differentiate between open and closed treatment; CPT only specifies
the site of the fracture: a Manipulation refers to the attempted reduction or restora-
tion of a dislocated joint or fracture (Smith 2015, 84)
3. In CPT, if a patient has two lacerations of the arm that are repaired with
simple closures, the coder would assign:
a.Two CPT codes expressing each laceration repair
b.One CPT code for the largest laceration
c.One CPT code, adding the lengths of the lacerations together
d.One CPT code for the most complex closure: c When multiple wounds are
repaired with the same closure type (for example, simple), lengths of the wounds in
the same classification and from all anatomical sites that are grouped together into
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the same code descriptor should be added together (Smith 2015, 67).
4. Patient admitted for laparoscopic repair of right diaphragmatic hernia. As-
sign the ICD-10-PCS procedure code for this surgery.
0BQR4ZZ Repair right diaphragm, percutaneous endoscopic approach
0BQROZZ Repair right diaphragm, open approach
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0BQS4ZZ Repair left diaphragm, percutaneous endoscopic approach
0BQSOZZ Repair left diaphragm, open approach
a.0BQR4ZZ
b.0BQR0ZZ
c.0BQS4ZZ
d.0BQS0ZZ: a Surgery is the only treatment for diaphragmatic hernias. ICD-10-PCS
code 0BQR4ZZ, is used for laparoscopic repair of diaphragmatic hernia (Garvin
2015, 192, 284)
5. When trying to determine if documentation is present to substantiate status
asthmaticus, the coder should review the record for what terms and phrases?
a.Intractable pneumonia
b.Refractory asthma and severe, intractable wheezing
c.Airway obstruction relieved by bronchodilators
d.Limited but pronounced wheezing: b Status asthmaticus is defined as continual
wheezing in spite of therapy (Leon-Chisen 2013, 230).
6. Gastrointestinal bleeding can manifest as:
a.Hematemesis, which indicates acute upper gastrointestinal hemorrhage
b.Petechia
c.Vomiting
d.Constipation, which indicates upper or lower gastrointestinal hemorrhage: a
Gastrointestinal bleeding manifests itself in several ways. These are hematemesis,
melena, occult bleeding, hematochezia (Leon-Chisen 2013, 244).
7. Which types of pacemaker devices have a unique ICD-10-PCS code.
a.Dual chamber rate responsive
b.Single chamber, single chamber rate responsive, and dual chamber
c.Multiple chamber
d.Multiple chamber rate responsive: b The three types of pacemakers are single
chamber, single chamber rate responsive, and dual chamber. A single chamber uses
a single lead; a dual chamber requires two leads, one in the atrium and one in the
ventricle. The leads should also be coded (Leon-Chisen 2013, 416-418).
8. Mechanical ventilation codes require consideration of which of the follow-
ing?
a.The time when a tracheal tube is inserted
b.The replacement of an endotracheal tube
c.The start time of endotracheal tube insertion followed by mechanical venti-
lation
d.Mechanical ventilation during surgery: c Codes for mechanical ventilation in-
dicate whether the patient was on mechanical ventilation for less than 24 hours,
24-96 consecutive hours and greater than 96 consecutive hours. The start time for
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calculating the duration begins with the start time of endotracheal tube insertion
as the best method, followed by mechanical ventilation or the time that a patient
who is on mechanical ventilation is admitted. The time ends with discontinuance of
mechanical ventilation (Leon-Chisen 2013, 239-240).
9. Abbreviations can be a source of patient safety issues due to misinterpre-
tation and miscommunication. Abbreviations in the health record:
a.Are not permitted by Joint Commission standards
b.Should have only one meaning
c.Enhance patient safety
d.Are critical to an electronic health record system: b The Joint Commission
has established a cautious quality approach to the use of abbreviations in all its
accredited organizations. To comply, every healthcare organization should strive to
limit or eliminate the use of abbreviations by developing an organizationspecific
abbreviation list so that only those abbreviations approved by the organization
are used. When more than one meaning for an approved abbreviation exists, an
organization should choose only one meaning or context in which the abbreviation
is to be used (Shaw and Carter 2014; Brodnik et al. 2012, 180-181).
10. In ICD-10-PCS, what value is used if there is a character that does not apply
to a given code?
a.X
b.Z
c.0
d.-: b All ICD-10-PCS codes must be seven characters, and a character cannot be
left blank. If a value does not exist for a given character, the Z is used as the value
(Shaw and Carter 2014; Kuehn and Jorwic 2013, 5).
11. Which symbol of punctuation is used in the Tabular List to enclose syn-
onyms, alternative wording, or explanatory phrases?
a.Parentheses
b.Brackets
c.Colon
d.Comma: a Punctuation is widely used in coding. Brackets are used in the Alpha-
betic Index to identify manifestation codes as well as to enclose synonyms, alterna-
tive wording or explanatory phrases. (ICD-10-CM Official Guidelines for Coding and
Reporting 2016b, 8)
12. When the documentation in the medical record is insufficient to assign a
more specific code, a code is assigned.
a.MCC
b.CC
c.NOS
