CDIP EVALUATION QUESTIONS AND ANSWERS SET
A+
✔✔An inpatient undergoes a procedure and has a postoperative complication during
the hospitalization. The insurance company will not pay for the entire amount requested.
Which POA indicator is likely part of the cause?
a.N
b.Y
c.W
d.U - ✔✔a The postoperative complication that is not present at admission. The
insurance company may not pay for the services provided to take care of the
postoperative complication (Garrett 2009, 11).
✔✔When trying to determine if documentation is present to substantiate status
asthmaticus, the coder should review the record for what terms and phrases?
a.Intractable pneumonia
b.Refractory asthma and severe, intractable wheezing
c.Airway obstruction relieved by bronchodilators
d.Limited but pronounced wheezing - ✔✔b Status asthmaticus is defined as continual
wheezing in spite of therapy (Leon-Chisen 2013, 230).
✔✔Within the postoperative patient, this is the most common type of shock. It occurs
when large amounts of fluids are lost from hemorrhage or severe dehydration.
a.Cardiogenic
b.Renal
c.Hypovolemic
d.Neurologic - ✔✔c Hypovolemic shock is the most common type of shock seen in the
postoperative patient. It occurs when large amounts of fluids are lost from hemorrhage
or severe dehydration (AHA 2011, 150).
✔✔The procedure that was performed for the definitive treatment (rather than the
diagnosis) of the main condition, or a complication of the condition is the:
a.Chief procedure
, b.Principal treatment
c.Principal procedure
d.Comorbidity - ✔✔c The principal procedure is the procedure that was performed for
the definitive treatment (rather than the diagnosis) of the main condition or a
complication of the condition (Shaw and Carter 2014; LaTour et al. 2013, 432,940).
✔✔A physician query may not be appropriate in which of the following instances?
a.Diagnosis of viral pneumonia noted in the progress notes and sputum cultures
showing
Haemophilus influenzae
b.Discharge summary indicates chronic renal failure but the progress notes document
acute renal failure throughout the stay
c.Acute respiratory failure in a patient whose lab report findings appear to not support
this diagnosis
d.Diagnosis of chest pain and abnormal cardiac enzymes indicative of an AMI - ✔✔c A
query may not be appropriate because the clinical information or clinical picture does
not appear to support the documentation of a condition or procedure. In situations in
which the provider's documented diagnosis does not appear to be supported by clinical
findings, a healthcare entity's policies can provide guidance on a process for addressing
the issue without querying the attending physician (Shaw and Carter 2014;
Schraffenberger and Kuehn 2011, 348).
✔✔Who is responsible for the content, quality, and signing of the discharge summary?
a.Attending physician
b.Head nurse
c.Consulting physician
d.Admitting nurse - ✔✔a The physician principally responsible for the patient's hospital
care generally dictates the discharge summary. However, a resident, physician
assistant, or nurse practitioner who is being supervised by the attending physician may
complete this task. Regardless of who documents it, the attending physician is
responsible for the content and quality of the summary and must date and sign it Shaw
and Carter 2014; Fahrenholz and Russo 2013, 284).
✔✔A coder notes that the patient is taking prescribed Haldol. The final diagnoses on the
progress notes include diabetes mellitus, acute pharyngitis, and malnutrition. What
condition might the coder suspect the patient has that the physician should be queried
to confirm?
a.Insomnia
b.Hypertension
c.Mental or behavioral problems
d.Rheumatoid arthritis - ✔✔c Haldol is a drug frequently administered for behavior or
mental conditions, so the coder would suspect mental or behavioral problems for this
patient. The physician must be queried to confirm the diagnosis. Documentation is
needed in the record to support the coding of the mental or behavioral problem (Shaw
and Carter 2014; Schraffenberger and Kuehn 2011, 285).
A+
✔✔An inpatient undergoes a procedure and has a postoperative complication during
the hospitalization. The insurance company will not pay for the entire amount requested.
Which POA indicator is likely part of the cause?
a.N
b.Y
c.W
d.U - ✔✔a The postoperative complication that is not present at admission. The
insurance company may not pay for the services provided to take care of the
postoperative complication (Garrett 2009, 11).
✔✔When trying to determine if documentation is present to substantiate status
asthmaticus, the coder should review the record for what terms and phrases?
a.Intractable pneumonia
b.Refractory asthma and severe, intractable wheezing
c.Airway obstruction relieved by bronchodilators
d.Limited but pronounced wheezing - ✔✔b Status asthmaticus is defined as continual
wheezing in spite of therapy (Leon-Chisen 2013, 230).
✔✔Within the postoperative patient, this is the most common type of shock. It occurs
when large amounts of fluids are lost from hemorrhage or severe dehydration.
a.Cardiogenic
b.Renal
c.Hypovolemic
d.Neurologic - ✔✔c Hypovolemic shock is the most common type of shock seen in the
postoperative patient. It occurs when large amounts of fluids are lost from hemorrhage
or severe dehydration (AHA 2011, 150).
✔✔The procedure that was performed for the definitive treatment (rather than the
diagnosis) of the main condition, or a complication of the condition is the:
a.Chief procedure
, b.Principal treatment
c.Principal procedure
d.Comorbidity - ✔✔c The principal procedure is the procedure that was performed for
the definitive treatment (rather than the diagnosis) of the main condition or a
complication of the condition (Shaw and Carter 2014; LaTour et al. 2013, 432,940).
✔✔A physician query may not be appropriate in which of the following instances?
a.Diagnosis of viral pneumonia noted in the progress notes and sputum cultures
showing
Haemophilus influenzae
b.Discharge summary indicates chronic renal failure but the progress notes document
acute renal failure throughout the stay
c.Acute respiratory failure in a patient whose lab report findings appear to not support
this diagnosis
d.Diagnosis of chest pain and abnormal cardiac enzymes indicative of an AMI - ✔✔c A
query may not be appropriate because the clinical information or clinical picture does
not appear to support the documentation of a condition or procedure. In situations in
which the provider's documented diagnosis does not appear to be supported by clinical
findings, a healthcare entity's policies can provide guidance on a process for addressing
the issue without querying the attending physician (Shaw and Carter 2014;
Schraffenberger and Kuehn 2011, 348).
✔✔Who is responsible for the content, quality, and signing of the discharge summary?
a.Attending physician
b.Head nurse
c.Consulting physician
d.Admitting nurse - ✔✔a The physician principally responsible for the patient's hospital
care generally dictates the discharge summary. However, a resident, physician
assistant, or nurse practitioner who is being supervised by the attending physician may
complete this task. Regardless of who documents it, the attending physician is
responsible for the content and quality of the summary and must date and sign it Shaw
and Carter 2014; Fahrenholz and Russo 2013, 284).
✔✔A coder notes that the patient is taking prescribed Haldol. The final diagnoses on the
progress notes include diabetes mellitus, acute pharyngitis, and malnutrition. What
condition might the coder suspect the patient has that the physician should be queried
to confirm?
a.Insomnia
b.Hypertension
c.Mental or behavioral problems
d.Rheumatoid arthritis - ✔✔c Haldol is a drug frequently administered for behavior or
mental conditions, so the coder would suspect mental or behavioral problems for this
patient. The physician must be queried to confirm the diagnosis. Documentation is
needed in the record to support the coding of the mental or behavioral problem (Shaw
and Carter 2014; Schraffenberger and Kuehn 2011, 285).
