CDIP Practice Exam 2 questions with correct answers

CDIP Practice Exam 2 questions with correct answers What coding system is published by the AMA and represents medical services and procedures performed by physicians and other healthcare providers. a.CPT b.ICD-10-PCS c.ICD-10 CM d.POA - Answer-a Level I of HCPCS is composed of the CPT codes as published by the AMA and represents medical services and procedures performed by physicians and other healthcare providers. The Level I (CPT) codes (other than the Category II and III codes) are five-digit numeric codes (Palkie 2013, 394). A patient has a prostate malignancy that had not been excised, removed, and still under treatment. The patient presents to the hospital with irregular heartbeat, malaise and gross hematuria with large amounts of blood being passed via the urethra with the inability to urinate. Patient was noted to have a hemoglobin of 10.8 due to significant blood loss, the patient was transfused and bladder irrigation was begun. Following significant irrigation, urine ran clear. Based on the above scenario, what is the principal diagnosis? a.Blood loss b.Prostate malignancy c.Gross hematuria d.Query warranted to determine the principal - Answer-c The diagnosis of gross hematuria should be selected as principal as the treatment was not directed toward the malignancy and the rule of assignment of the principal diagnosis would apply to this circumstance (AHA Second Quarter 2010). Based on the diagnosis of gross hematuria, signs and symptoms of irregular heartbeat, malaise, and hemoglobin of 10.8 with transfusion, query for anemia due to blood loss may be______: a.Appropriate b.Inappropriate - Answer-a The generation of a query should be considered when the health record documentation: •Is conflicting, imprecise, incomplete, illegible, ambiguous, or inconsistent •Describes or is associated with clinical indicators without a definitive relationship to an underlying diagnosis •Includes clinical indicators, diagnostic evaluation, and/or treatment not related to a specific condition or procedure •Provides a diagnosis without underlying clinical validation •Is unclear for present on admission indicator assignment The _________ diagnosis is designated and defined as the condition established after study to be chiefly responsible for occasioning the admission of the patient to the hospital