CDIP DOMAIN 1 CLINICAL CODING PRACTICE EXAM QUESTIONS AND ANSWERS.
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Module
CDIP
Institution
CDIP
Principal Diagnosis
The disease or condition that was present on admission, was the principal reason for admission, and received treatment or evaluation during the hospital stay or visit for the reason established after study to be chiefly responsible for occasioning the admission of the patient t...
CDIP DOMAIN 1: CLINICAL CODING
PRACTICE EXAM QUESTIONS AND
ANSWERS
Principal Diagnosis - answer The disease or condition that was present on admission, was the principal
reason for admission, and received treatment or evaluation during the hospital stay or visit for the
reason established after study to be chiefly responsible for occasioning the admission of the patient to
the hospital for care
First Listed Diagnosis - answer Used in the outpatient setting, this term is used (instead of the inpatient
setting's principal diagnosis), and it is determined in accordance with ICD-10-CM's coding conventions
(or rules) as well as general and disease-specific coding guidelines.
Secondary Diagnosis - answer A statement of those conditions coexisting during a hospital episode that
affect the treatment received or the length of stay
Value of Utilizing Coding Software - answer Accurate Coding, increase in productivity, Grouping, Edits,
and Resources.
7 Characteristics of High Quality Documentation - answer 1. clear
2. consistent
3. complete
4. precise
5. legible
6. timely
7. reliable
, Complication - answer Conditions that develop in a patient already suffering from a disease - prolongs
the length of stay by at least 1 day in about 75% of the cases
Comorbidity - answer a pre-existing condition which of its presence with the principal diagnosis will
increase the length of stay by at least 1 day in 75% of the cases
Medicare - answer CMS- Establish rules
MS-DRG - is used for reimbursement
Medicaid - answer is handle by individual states
primary insurance - answer own rules and regulations per plan
MS- DRG - answer Medicare Severity Diagnosis Related Group
PPS (Prospective Payment System) - answer fixed payment scale/schedule based o your DRG, effected
Medicare Part A, resulted in shorter hospital stays
APR - DRG - answer All Patient Refined Diagnosis-Related Group
SOI - answer Severity of Illness
ROM - answer Risk of Mortality
APR-DRG Four Levels - answer 1. Minor
2. Moderate
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