CDIP Practice Exam 2 Save
Terms in this set (119)
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
,If the physician does not document the c The coder cannot assume diagnoses on abnormal findings
diagnosis, the coding professional cannot such as lab reports. Abnormal findings (laboratory, X-ray,
assume the patient has a diagnosis based pathologic, and other diagnostic results) are not coded and
solely on reported unless the physician indicates their clinical
a.An abnormal lab finding significance. If the findings are outside the normal range and
b.Abnormal pathology reports the physician has ordered other tests to evaluate the
c.Both A and B condition or prescribed treatment, it is appropriate to ask the
d.None of the above physician whether the diagnosis should be added (AHA 1990,
15).
These documents would be used for are c Clinicians and providers utilize various documents to
used by clinicians and providers to identify identify abnormal temperature, blood pressure, pulse,
abnormal temperature, blood pressure, respiration, oxygen levels, and other indicators. These
pulse, respiration, oxygen levels, and other documents are often called nurses' graphic records or vital
indicators. sign flowsheets (Hess 2015, 43).
a.Nurses' graphic records
b.Vital sign flowsheets
c.Both A and B
d.None of the above
,The American Hospital Association (AHA), a The American Hospital Association (AHA), the American
the American Health Information Health Information Management Association (AHIMA),
Management Association (AHIMA), Center Center for Medicare and Medicaid Services (CMS), and
for Medicare and Medicaid Services (CMS), National Center for Health Statistics (NCHS) are all
and National Center for Healthcare cooperating parties that developed and approved ICD-10-
Statistics (NCHS) are all CM/PCS (ICD-10-CM Official Guidelines for Coding and
a.Cooperating parties Reporting 2016a, 1).
b.Governing bodies
c.Coding associations
d.Work independently to develop coding
guidelines
A patient was admitted with HIV and a If a patient is admitted for an HIV-related condition, the
pneumocystic carini. The patient should principal diagnosis should be B20, Human immunodeficiency
have a principal diagnosis in ICD-10 of: virus [HIV] disease followed by additional diagnosis codes
a.AIDS for all reported HIV-related conditions (ICD-10-CM Official
b.Asymptomatic HIV Guidelines for Coding and Reporting 2016a, 17).
c.Pneumonia
d.Not enough information
APR-DRGs have levels (subclasses) of b The APR-DRG system is distributed into levels (subclasses)
severity entitled: similar to MS-DRGs. These levels are entitled Extreme, Major,
a.Excessive, Major, Moderate, Minor Moderate, Minor (Hess 2015, 48)
b.Extreme, Major, Moderate, Minor
c.Extreme, Major, Moderate, Minimal
d.Excessive, Major
, During an outpatient procedure for removal a When a patient presents for outpatient surgery and
of a bladder cyst, the urologist accidentally develops complications requiring admission to observation,
tore the urethral sphincter requiring an code the reason for the surgery as the first reported
observation stay. This should be assigned as diagnosis (reason for the encounter), followed by codes for
the principal diagnosis: the complications as secondary diagnoses (ICD-10-CM
a.The reason for the outpatient surgery Official Guidelines for Coding and Reporting 2016a, 103).
b.The reason for admission
c.Either the reason for the outpatient
surgery or the reason for admission
d.None of the above
In 1990, 3M created which DRG system that c In 1990, 3M created APR-DRGs, which several states use for
several states use for Medicaid Medicaid reimbursement. APR-DRGs are used by facilities to
reimbursement and is also used by facilities analyze some portion of the data for Medicare Quality
to analyze some portion of the data for Indicators (Hess 2015, 48)
Medicare Quality Indicators. What is this
system called?
a.MS-DRGs
b.AP-DRGs
c.APR-DRGs
d.CPT-DRGs
Terms in this set (119)
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
,If the physician does not document the c The coder cannot assume diagnoses on abnormal findings
diagnosis, the coding professional cannot such as lab reports. Abnormal findings (laboratory, X-ray,
assume the patient has a diagnosis based pathologic, and other diagnostic results) are not coded and
solely on reported unless the physician indicates their clinical
a.An abnormal lab finding significance. If the findings are outside the normal range and
b.Abnormal pathology reports the physician has ordered other tests to evaluate the
c.Both A and B condition or prescribed treatment, it is appropriate to ask the
d.None of the above physician whether the diagnosis should be added (AHA 1990,
15).
These documents would be used for are c Clinicians and providers utilize various documents to
used by clinicians and providers to identify identify abnormal temperature, blood pressure, pulse,
abnormal temperature, blood pressure, respiration, oxygen levels, and other indicators. These
pulse, respiration, oxygen levels, and other documents are often called nurses' graphic records or vital
indicators. sign flowsheets (Hess 2015, 43).
a.Nurses' graphic records
b.Vital sign flowsheets
c.Both A and B
d.None of the above
,The American Hospital Association (AHA), a The American Hospital Association (AHA), the American
the American Health Information Health Information Management Association (AHIMA),
Management Association (AHIMA), Center Center for Medicare and Medicaid Services (CMS), and
for Medicare and Medicaid Services (CMS), National Center for Health Statistics (NCHS) are all
and National Center for Healthcare cooperating parties that developed and approved ICD-10-
Statistics (NCHS) are all CM/PCS (ICD-10-CM Official Guidelines for Coding and
a.Cooperating parties Reporting 2016a, 1).
b.Governing bodies
c.Coding associations
d.Work independently to develop coding
guidelines
A patient was admitted with HIV and a If a patient is admitted for an HIV-related condition, the
pneumocystic carini. The patient should principal diagnosis should be B20, Human immunodeficiency
have a principal diagnosis in ICD-10 of: virus [HIV] disease followed by additional diagnosis codes
a.AIDS for all reported HIV-related conditions (ICD-10-CM Official
b.Asymptomatic HIV Guidelines for Coding and Reporting 2016a, 17).
c.Pneumonia
d.Not enough information
APR-DRGs have levels (subclasses) of b The APR-DRG system is distributed into levels (subclasses)
severity entitled: similar to MS-DRGs. These levels are entitled Extreme, Major,
a.Excessive, Major, Moderate, Minor Moderate, Minor (Hess 2015, 48)
b.Extreme, Major, Moderate, Minor
c.Extreme, Major, Moderate, Minimal
d.Excessive, Major
, During an outpatient procedure for removal a When a patient presents for outpatient surgery and
of a bladder cyst, the urologist accidentally develops complications requiring admission to observation,
tore the urethral sphincter requiring an code the reason for the surgery as the first reported
observation stay. This should be assigned as diagnosis (reason for the encounter), followed by codes for
the principal diagnosis: the complications as secondary diagnoses (ICD-10-CM
a.The reason for the outpatient surgery Official Guidelines for Coding and Reporting 2016a, 103).
b.The reason for admission
c.Either the reason for the outpatient
surgery or the reason for admission
d.None of the above
In 1990, 3M created which DRG system that c In 1990, 3M created APR-DRGs, which several states use for
several states use for Medicaid Medicaid reimbursement. APR-DRGs are used by facilities to
reimbursement and is also used by facilities analyze some portion of the data for Medicare Quality
to analyze some portion of the data for Indicators (Hess 2015, 48)
Medicare Quality Indicators. What is this
system called?
a.MS-DRGs
b.AP-DRGs
c.APR-DRGs
d.CPT-DRGs
