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CDIP Practice Exam Questions and Answers 2025.
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CDIP Practice Exam Questions and Answers 2025.
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CDIP Practice Exam Questions and Answers 2025.A physician admits a patient with shortness of breath and chest pain,
patient withthe
then treats Lasix, oxygen, and Theophylline. The physician's final
documented
diagnosis for the patient is acute exacerbation of COPD. What is missing
from this that would make it reliable information in the treatment of
diagnosis
this patient?
a.No additional information is
needed.
b.The type of
COPD
c.The reason the patient was treated
with Lasix
d.The reason for the Theophylline - Answer-
If the physician does not document the diagnosis, the coding
assume the patient
professional cannot has a diagnosis based
solelyabnormal
a.An on lab
finding
b.Abnormal pathology
reports
c.Both A and
B
d.None of the above - Answer- c The coder cannot assume diagnoses on
findings such as lab reports. Abnormal findings (laboratory, X-ray,
abnormal
pathologic,results)
diagnostic and other
are not coded and reported unless the physician
indicates
clinical their
significance. If the findings are outside the normal range and the
physician
ordered other
has tests to evaluate the condition or prescribed treatment, it is
appropriate
ask to
the physician whether the diagnosis should be added (AHA
1990, 15).
These documents would be used for are used by clinicians and providers
to identify temperature, blood pressure, pulse, respiration, oxygen levels,
abnormal
and other
indicator
a.Nurses' graphic
s.
records
b.Vital sign
flowsheets
c.Both A and
B
d.None of the above - Answer- c Clinicians and providers utilize various
documents
identify to
abnormal temperature, blood pressure, pulse, respiration, oxygen
levels,indicators.
other and These documents are often called nurses' graphic records
or vital sign(Hess 2015, 43).
flowsheets
The American Hospital Association (AHA), the American Health
Management Association (AHIMA), Center for Medicare and Medicaid
Information
Services
and (CMS),
National Center for Healthcare Statistics (NCHS)
are all
a.Cooperating
parties
b.Governing
bodies
c.Coding
associations
d.Work independently to develop coding guidelines - Answer- a The
American Hospital
Association (AHA), the American Health Information Management Association
(AHIMA),
Center for Medicare and Medicaid Services (CMS), and National Center
for Health
1
,Statistics (NCHS) are all cooperating parties that developed and
approved ICD-10- CM/PCS (ICD-10-CM Official Guidelines for Coding and
Reporting 2016a, 1).
principal
A patient diagnosis
was admitted
in ICD-
with HIV and pneumocystic carini. The patient
10 of: have a
a.AIDS
should
b.Asymptomatic
HIV
c.Pneumoni
a
d.Not enough information - Answer- a If a patient is admitted for an
HIV-related
condition, the principal diagnosis should be B20, Human immunodeficiency
virus [HIV]
disease followed by additional diagnosis codes for all reported HIV-related
(ICD-10-CM Official Guidelines for Coding and Reporting
conditions
2016a, 17).
a.Excessive,
APR-DRGs haveMajor, Moderate,
levels (subclasses) of severity entitled:
Minor
b.Extreme, Major, Moderate,
Minor
c.Extreme, Major, Moderate,
Minimal
d.Excessive, Major - Answer- b The APR-DRG system is distributed
into levels similar to MS-DRGs. These levels are entitled Extreme, Major,
(subclasses)
Moderate,
Minor (Hess 2015, 48)
During an outpatient procedure for removal of a bladder cyst, the urologist
accidentally tore the urethral sphincter requiring an observation stay. This
principal
should be assigned as the
diagnosis:
a.The reason for the outpatient
surgery
b.The reason for
admission
c.Either the reason for the outpatient surgery or the reason for
admission
d.None of the above - Answer- a When a patient presents for outpatient
surgery and
develops complications requiring admission to observation, code the
reason for
surgery as the
the first reported diagnosis (reason for the encounter), followed
by codes
the complications
for as secondary diagnoses (ICD-10-CM Official Guidelines
for Coding
and Reporting 2016a, 103).
In 1990, 3M created which DRG system that several states use for
reimbursement and is also used by facilities to analyze some portion of
Medicaid
the data for
Medicare Quality Indicators. What is this system
a.MS-
called?
DRGs
b.AP-DRGs
c.APR-DRGs
d.CPT-DRGs - Answer- c In 1990, 3M created APR-DRGs, which several states
use for reimbursement. APR-DRGs are used by facilities to analyze some
Medicaid
portion
the dataoffor Medicare Quality Indicators (Hess
2015, 48)
A patient was admitted to an acute care facility with a temperature of
102 and atrial
fibrillation. The chest x-ray reveals pneumonia with subsequent
documentation by the in the progress notes and discharge summary. The
physician of pneumonia
patient was
2
,treated with oral antiarrhythmia medications and IV antibiotics. What is
diagnosis
the principal
?
a.Pneumoni
a
b.Arrhythmi
a
c.Atrial
fibrillation
d.Both a and c - Answer- a The patient presented with clinical signs of
Pneumonia
with along
treatment. The atrial fibrillation was a chronic condition that can
be reported (CMS 2016b).
additionally
The Cooperating Parties, which develop and approve ICD-10,
a.American Hospital Association (AHA) and American Health Information
include:
Management
Association
(AHIMA)
b.American Hospital Association (AHA), American Health Information
Management
Association (AHIMA), and Centers for Disease Control
(CDC)
c.American Hospital Association (AHA), American Health Information
Management
Association (AHIMA), and Centers for Medicare and Medicaid Services
(CMS), and
National Center for Health Statistics
(NCHS)
d.American Hospital Association (AHA), American Health Information
Management
Association (AHIMA), and the World Health Organization (WHO) -
Answer- c The
cooperating parties developed and approved ICD-10-CM/PCS and
include (4)
organizations American Hospital Association (AHA), American Health
Information
Management Association (AHIMA), and Centers for Medicare and Medicaid
Services
(CMS), and National Center for Health Statistics (NCHS) (CMS 2016c).
Mildred Smith was admitted to a nursing facility with the following
being admitted
information: for Organic
"Patient is Brain Syndrome." Underneath the diagnosis,
her medical was listed along with a summary of the care already
information
provided.
informationThis
is documented on
the:
a.Transfer
record
b.Release of information
c.Patient's rights acknowledgment
form
form
d.Admitting physical evaluation record - Answer- a Transfer records
are createda patient is transferred from one facility to another. The
whenever
transfer record
contains a summary of the care provided in the facility from which the
patient is being
transferred as well as the reason for transfer. Transfer records are
important to
continuum ofthe
care because they document communication between
caregivers
multiple settings
in (Shaw and Carter 2014; Fahrenholz and Russo
2013, 225).
A 65-year-old white male was admitted to the hospital on 1/15 complaining of
abdominal
pain. The attending physician requested an upper GI series and laboratory
evaluation
CBC and UA.of The x-ray revealed possible cholelithiasis and the UA
showed anwhite blood cell count. The patient was taken to surgery for an
increased
exploratory
laparoscopy and a ruptured appendix was discovered. The chief
complaint was:
a.Ruptured
appendix
b.Exploratory
laparoscopy
c.Abdominal
pain
3
, d.Cholelithiasis - Answer- c The abdominal pain is the chief complaint and is
reason presented/reason for visit (Shaw and Carter 2014; Fahrenholz
the patient
and Russo
2013,
225).
A patient arrived via ambulance to the emergency department following a
accident.
motor vehicleThe patient sustained a fracture of the ankle, 3.0 cm superficial
laceration
the left arm,of 5.0 cm laceration of the scalp with exposure of the
fascia, and aThe patient received the following procedures: x-ray of the
concussion.
ankle that
showed a bimalleolar ankle fracture requiring closed manipulative reduction
and simple
suturing of the arm laceration and layer closure of the scalp. Provide CPT
codes for the
procedures done in the emergency department for the
facility Simple
12002 bill. repair of superficial wounds of scalp, neck, axillae,
external
trunk genitalia,
and/or extremities (including hands and feet); 2.6 cm
to 7.5 cm
12004 Simple repair of superficial wounds of scalp, neck, axillae,
external
trunk genitalia,
and/or extremities (including hands and feet); 7.6 cm
to 12.5Repair,
12032 cm intermediate, wounds of scalp, axillae, trunk and/or
extremities
(excluding hands and feet); 2.6 cm to
7.5 cm Closed treatment of bimalleolar ankle fracture (e.g., lateral and
27810
medial
or malleoli,
lateral and posterior malleoli, or medial and posterior malleoli); with
manipulation
27818 Closed treatment of trimalleolar ankle fracture; with
manipulation
a.27810,
12032
b.27818, 12004,
12032
c.27810, 12032,
12002
d.27810, 12004 - Answer- c The closed reduction of the fracture is coded
first following
principal procedure guidelines. The laceration repair is also coded. When
moreclassification
one than of wound repair is performed, all codes are reported with
code for
the most complicated procedure listed first (Kuehn 2013, 26-27, 111-
113).
hemoglobin of 8.8 with blood
The appeal coordinator in stool
received noted
a denial in stated:
that physician
Onoffice...patient
presentation,
sent
admission
as had
patient direct
straight to hospital. The physician notes 11/05/14 states GI
bleeding transfusion
consider will 11/06/14. Note also states melenic stools and states
hemoccult
positive. Endoscopy report states - Acute Posthemorrhagic Anemia with iron
deficiency
anemia due to blood loss. "Multiple small angioectasias without bleeding
weresecond
the found part
in of the duodenum. Red blood was found on the greater
curvature Multiple
stomach. of the small angioectasias with stigmata of recent bleeding
weregastric
the found body.
in No active bleeding or clear which angioectasia are
bleedingrecently
Multiple source."bleeding angioectasias in the stomach. Hemoglobin and
hematocrit
low on admission and decreased following admission at 8.8 to 8.2 and
27.8 to 26.8 Patient transfused packed RBCs on
respectively.
11/5/14.
Based on the above information , the review
contractor:
a.Denied the DRG
inappropriately
b.Was correct to deny the DRG, no query
needed
c.Should not have denied the
DRG
d.Was correct to deny, query needed - Answer- a The assignment of
the code is If the physician clearly documents the anemia is due to acute
appropriate.
blood loss,
4
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