CDIP Practice Exam 2 Questions With Correct Answers

CDIP Practice Exam 2 Questions With Correct Answers 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 - CORRECT ANSWERS 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 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 - CORRECT ANSWERS 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 - CORRECT ANSWERS 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). 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 - CORRECT ANSWERS 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 - CORRECT ANSWERS 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 d.None of the above - CORRECT ANSWERS 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 - CORRECT ANSWERS 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 d.Both a and c - CORRECT ANSWERS a The patient presented with clinical signs of Pneumonia along with treatment. The atrial fibrillation was a chronic condition that can be reported additionally (CMS 2016b).