CDIP EXAM 2026 HIGH-YIELD MEDICAL
RECORDS ACCURACY AND CLINICAL
CODING CONCEPTS STUDY MATERIALS
◉ Secondary Diagnosis.
Answer: A statement of those conditions coexisting during a hospital
episode that affect treatment received or length of stay
◉ Where to find the pertinent diagnosis.
Answer: 1. H&P
2. Progress Notes
3. Clinical Notes
4. Operative/Pathology Report
5. Procedure Notes
6. Lab/Radiology Findings
7. Discharge Summary
◉ 7 Characteristics of High Quality Clinical Documentation.
Answer: Clear
Consistent
Complete
,Precise
Legible
Timely
Reliable
◉ first-listed diagnosis.
Answer: in the outpatient setting, the primary diagnosis is the main
reason for the visit. it is usually the diagnosis taking the majority of
resources for the visit
◉ CC.
Answer: conditions and comorbidities
◉ MCC.
Answer: Major Conditions and Comorbidities
◉ Perspective Payment Systems.
Answer: Predetermined payment based on service provided; began
as inpatient but moved to different healthcare areas
◉ MSDRG.
Answer: Medicare Severity Diagnosis Related Groups
,◉ MDC.
Answer: Major Diagnostic Category - represents the body systems
treated by medicine. (There are 25 MDCs). Examples: 1) diseases
and disorders of the nervous system, 2) diseases and disorders of
the eye, 3) infectious and parasitic diseases, 4) HIV, 5) endocrine &
metabolic disorders, 6) pregnancy, childbirth, and the puerperium,
etc...
◉ ICD-10-CM.
Answer: International Classification of Diseases, 10th Revision,
Clinical Modification
◉ ICD-10 Procedure Coding System (ICD-10-PCS).
Answer: - a system of medical classification used for procedural
codes - for hospital inpatient use only
◉ Encoder.
Answer: Specialty software used to facilitate the assignment of
diagnostic and procedural codes according to the rules of the coding
system
◉ Why use coding software?.
Answer: Accurate coding
, Productivity
Grouping
Edits
Resources
◉ Complication.
Answer: Condition arising during hospital stay that prolongs length
of stay by at least 1 day in approx. 75% of cases
◉ Comorbidity.
Answer: A pre-existing condition which because of its presence with
the principal diagnosis will increase the length of stay by at least 1
day in approx. 75% of cases
◉ APR-DRG.
Answer: All Patient Refined Diagnosis-Related Groups
◉ Severity of Illness (SOI).
Answer: extent of physiological decompensation or organ system
loss of function.
◉ Risk of Mortality (ROM).
Answer: the likelihood of dying.
RECORDS ACCURACY AND CLINICAL
CODING CONCEPTS STUDY MATERIALS
◉ Secondary Diagnosis.
Answer: A statement of those conditions coexisting during a hospital
episode that affect treatment received or length of stay
◉ Where to find the pertinent diagnosis.
Answer: 1. H&P
2. Progress Notes
3. Clinical Notes
4. Operative/Pathology Report
5. Procedure Notes
6. Lab/Radiology Findings
7. Discharge Summary
◉ 7 Characteristics of High Quality Clinical Documentation.
Answer: Clear
Consistent
Complete
,Precise
Legible
Timely
Reliable
◉ first-listed diagnosis.
Answer: in the outpatient setting, the primary diagnosis is the main
reason for the visit. it is usually the diagnosis taking the majority of
resources for the visit
◉ CC.
Answer: conditions and comorbidities
◉ MCC.
Answer: Major Conditions and Comorbidities
◉ Perspective Payment Systems.
Answer: Predetermined payment based on service provided; began
as inpatient but moved to different healthcare areas
◉ MSDRG.
Answer: Medicare Severity Diagnosis Related Groups
,◉ MDC.
Answer: Major Diagnostic Category - represents the body systems
treated by medicine. (There are 25 MDCs). Examples: 1) diseases
and disorders of the nervous system, 2) diseases and disorders of
the eye, 3) infectious and parasitic diseases, 4) HIV, 5) endocrine &
metabolic disorders, 6) pregnancy, childbirth, and the puerperium,
etc...
◉ ICD-10-CM.
Answer: International Classification of Diseases, 10th Revision,
Clinical Modification
◉ ICD-10 Procedure Coding System (ICD-10-PCS).
Answer: - a system of medical classification used for procedural
codes - for hospital inpatient use only
◉ Encoder.
Answer: Specialty software used to facilitate the assignment of
diagnostic and procedural codes according to the rules of the coding
system
◉ Why use coding software?.
Answer: Accurate coding
, Productivity
Grouping
Edits
Resources
◉ Complication.
Answer: Condition arising during hospital stay that prolongs length
of stay by at least 1 day in approx. 75% of cases
◉ Comorbidity.
Answer: A pre-existing condition which because of its presence with
the principal diagnosis will increase the length of stay by at least 1
day in approx. 75% of cases
◉ APR-DRG.
Answer: All Patient Refined Diagnosis-Related Groups
◉ Severity of Illness (SOI).
Answer: extent of physiological decompensation or organ system
loss of function.
◉ Risk of Mortality (ROM).
Answer: the likelihood of dying.
