CDIP DOMAIN 4 CDI EXAM SCRIPT 2026
COMPLETE QUESTIONS AND CORRECT
ANSWERS
◉ CPT. Answer: Current Procedural Terminology
◉ MS-DRGs. Answer: Medicare Severity-Diagnosis Related Groups
◉ CPT Assistant. Answer: Monthly publication by the AMA that
provides coding advice for CPT coding scenarios
◉ Encoder Nosology. Answer: Provides coding professionals from
the encoder company that are available to help answer tough coding
questions
◉ History & Physical. Answer: Provides the initial chief complaint
and initial impressions of the provider when the patient is first
admitted. It also has a comprehensive physical review of the
patient's body systems and vital signs, and provides the initial
treatment plan, medications, and tests that are being ordered to
treat the patient.
, ◉ Progress Notes. Answer: Provide information about what is going
on with the patient on a day-to-day basis; they should include the
diagnoses that are being treated as well as any information about
any changes in the patient's well-being and tests/procedures being
performed.
◉ Operative and Pathology Reports. Answer: Summarize the
invasive procedures performed and any samples that are removed
from the patient's body
◉ Pathology report. Answer: Provides detailed information from the
pathologist of the facility as to the status of the tissues or organs
removed from the patient's body
◉ Encoder. Answer: Specialty software used to facilitate the
assignment of diagnostic and procedural codes according to the
rules of the coding system
◉ What is the value of utilizing coding software?. Answer: It
facilitates accurate coding by providing links to coding resources,
groups diagnosis and procedure codes to the correct MS-DRG, and
provides edits with additional information for the coder to consider
when placing codes into the encoder
◉ Principal diagnosis. Answer: Diagnosis that, after study, is the
reason for the patient's admission to the hospital.
COMPLETE QUESTIONS AND CORRECT
ANSWERS
◉ CPT. Answer: Current Procedural Terminology
◉ MS-DRGs. Answer: Medicare Severity-Diagnosis Related Groups
◉ CPT Assistant. Answer: Monthly publication by the AMA that
provides coding advice for CPT coding scenarios
◉ Encoder Nosology. Answer: Provides coding professionals from
the encoder company that are available to help answer tough coding
questions
◉ History & Physical. Answer: Provides the initial chief complaint
and initial impressions of the provider when the patient is first
admitted. It also has a comprehensive physical review of the
patient's body systems and vital signs, and provides the initial
treatment plan, medications, and tests that are being ordered to
treat the patient.
, ◉ Progress Notes. Answer: Provide information about what is going
on with the patient on a day-to-day basis; they should include the
diagnoses that are being treated as well as any information about
any changes in the patient's well-being and tests/procedures being
performed.
◉ Operative and Pathology Reports. Answer: Summarize the
invasive procedures performed and any samples that are removed
from the patient's body
◉ Pathology report. Answer: Provides detailed information from the
pathologist of the facility as to the status of the tissues or organs
removed from the patient's body
◉ Encoder. Answer: Specialty software used to facilitate the
assignment of diagnostic and procedural codes according to the
rules of the coding system
◉ What is the value of utilizing coding software?. Answer: It
facilitates accurate coding by providing links to coding resources,
groups diagnosis and procedure codes to the correct MS-DRG, and
provides edits with additional information for the coder to consider
when placing codes into the encoder
◉ Principal diagnosis. Answer: Diagnosis that, after study, is the
reason for the patient's admission to the hospital.
