EMILLYCHARLOTTE 2024/2025 ACADEMIC YEAR ©2024 ALL RIGHTS RESERVED,
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CDIP Practice Exam 2 Practice
Questions and Answers | 100% Pass
A physician admits a patient with shortness of breath and chest pain, then treats the
patient with Lasix, oxygen, and Theophylline. The physician's final documented
diagnosis for the patient is acute exacerbation of COPD. What is missing from this
diagnosis that would make it reliable information in the treatment of 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 professional cannot
assume the patient has a diagnosis based solely on
a.An abnormal lab finding
b.Abnormal pathology reports
c.Both A and B
d.None of the above - Answer✔✔-c The coder cannot assume diagnoses on
abnormal findings such as lab reports. Abnormal findings (laboratory, X-ray, pathologic,
and other diagnostic results) are not coded and reported unless the physician indicates
their clinical significance. If the findings are outside the normal range and the physician
has ordered other tests to evaluate the condition or prescribed treatment, it is
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appropriate to ask 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
abnormal temperature, blood pressure, pulse, respiration, oxygen levels, and other
indicators.
a.Nurses' graphic records
b.Vital sign flowsheets
c.Both A and B
d.None of the above - Answer✔✔-c Clinicians and providers utilize various
documents to identify abnormal temperature, blood pressure, pulse, respiration, oxygen
levels, and other indicators. These documents are often called nurses' graphic records
or vital sign flowsheets (Hess 2015, 43).
The American Hospital Association (AHA), the American Health Information
Management Association (AHIMA), Center for Medicare and Medicaid Services (CMS),
and 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 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).
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A patient was admitted with HIV and pneumocystic carini. The patient should have a
principal diagnosis in ICD-10 of:
a.AIDS
b.Asymptomatic HIV
c.Pneumonia
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 conditions
(ICD-10-CM Official Guidelines for Coding and Reporting 2016a, 17).
APR-DRGs have levels (subclasses) of severity entitled:
a.Excessive, Major, Moderate, Minor
b.Extreme, Major, Moderate, Minor
c.Extreme, Major, Moderate, Minimal
d.Excessive, Major - Answer✔✔-b The APR-DRG system is distributed into levels
(subclasses) similar to MS-DRGs. These levels are entitled Extreme, Major, 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 should be assigned as the
principal 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
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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 the
surgery as the first reported diagnosis (reason for the encounter), followed by codes for
the complications 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 Medicaid
reimbursement and is also used by facilities to analyze some portion of the data for
Medicare Quality Indicators. What is this system called?
a.MS-DRGs
b.AP-DRGs
c.APR-DRGs
d.CPT-DRGs - Answer✔✔-c In 1990, 3M created APR-DRGs, which several states
use for Medicaid reimbursement. APR-DRGs are used by facilities to analyze some
portion of the data for 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
physician of pneumonia in the progress notes and discharge summary. The patient was
treated with oral antiarrhythmia medications and IV antibiotics. What is the principal
diagnosis?
a.Pneumonia
b.Arrhythmia
c.Atrial fibrillation
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