Certified Documentation Integrity Practitioner (CDIP®)
Exam Prep 2026 Updated Practice Questions –
Comprehensive Clinical Documentation Improvement
Review Detailed Explanations – Verified Answers –
Complete Success Workbook
SECTION 1: CLINICAL CODING PRACTICE (15–18% of Exam)
Question 1
A patient is admitted with chest pain and is subsequently diagnosed with acute
myocardial infarction (AMI) of the anterolateral wall. The physician documents
"acute myocardial infarction" without specifying the site. What is the correct ICD-
10-CM code assignment?
A) I21.09 – Acute myocardial infarction, unspecified
B) I21.09 – Acute myocardial infarction, unspecified
C) I21.19 – Acute myocardial infarction, other
D) I21.4 – Non-ST elevation (NSTEMI) myocardial infarction
Rationale: When the physician documents "acute myocardial infarction" without
specifying the site or type (STEMI vs. NSTEMI), the correct code is I21.09 (Acute
myocardial infarction, unspecified). The coder should not assume the site or type
without clear documentation. If the documentation lacks specificity, the CDI
specialist should query the physician for clarification.
Question 2
A patient is admitted with HIV and Pneumocystis jiroveci pneumonia. What is the
correct principal diagnosis?
A) Asymptomatic HIV
B) Pneumonia
C) B20 – HIV disease
D) B20 and B59 – HIV with Pneumocystis pneumonia
,Rationale: When a patient is admitted for an HIV-related condition, the principal
diagnosis should be B20 (HIV disease). The pneumonia is coded as a secondary
diagnosis. The pneumonia is an HIV-related opportunistic infection, and the HIV is
the underlying condition chiefly responsible for the admission.
Question 3
A patient is admitted with congestive heart failure due to hypertension. Which of
the following code assignments is correct?
A) I10, I50.9
B) I11.0, I50.9
C) I11.0 only
D) I50.9 only
Rationale: When a causal relationship is stated ("due to hypertension"), a
combination code is assigned. I11.0 (Hypertensive heart disease with heart failure)
is the combination code, and an additional code (I50.9) identifies the type of heart
failure.
Question 4
A patient is admitted with acute exacerbation of COPD and pneumonia. The
physician documents both conditions as equally contributing to the admission.
What is the correct ICD-10-CM code?
A) J44.1 – COPD with (acute) exacerbation
B) J44.0 – COPD with acute lower respiratory infection
C) J18.9 – Pneumonia, unspecified organism
D) J44.9 – COPD, unspecified
Rationale: When a patient with COPD has an acute exacerbation and pneumonia,
ICD-10-CM guidelines state that the combination code J44.0 (Chronic obstructive
pulmonary disease with acute lower respiratory infection) should be used. This
combination code captures both the COPD exacerbation and the pneumonia, as
pneumonia is a lower respiratory infection.
,Question 5
A patient is admitted with sepsis due to a urinary tract infection (UTI). What is the
correct ICD-10-CM code assignment?
A) A41.9 – Sepsis, unspecified organism
B) N39.0 – Urinary tract infection, site not specified
C) A41.9 with N39.0 – Sepsis due to UTI
D) R65.20 – Severe sepsis without septic shock
Rationale: ICD-10-CM provides combination codes for sepsis due to a specific
organism or source. When sepsis is due to a urinary tract infection, the
combination code should be used rather than coding the conditions separately. The
sepsis code is sequenced as the principal diagnosis, followed by the UTI code.
Question 6
According to ICD-10-CM Official Guidelines, what is the correct coding for
"status asthmaticus"?
A) J45.901 – Unspecified asthma with (acute) exacerbation
B) J45.902 – Unspecified asthma with status asthmaticus
C) J45.909 – Unspecified asthma, uncomplicated
D) J45.998 – Other asthma
Rationale: Status asthmaticus is a specific, severe form of asthma that does not
respond to standard treatment. The correct code is J45.902 (Unspecified asthma
with status asthmaticus). If the type of asthma is specified (e.g., allergic), the more
specific code for that type with status asthmaticus would be used.
Question 7
A patient undergoes a laparoscopic cholecystectomy. What is the correct ICD-10-
PCS root operation?
A) Resection
B) Excision
C) Removal
D) Destruction
, Rationale: In ICD-10-PCS, the root operation Excision is defined as cutting out or
off, without replacement, a portion of a body part. A cholecystectomy involves the
removal of the gallbladder, which is a portion of the biliary
system. Resection would be used if the entire body part were removed.
Question 8
A patient is admitted with acute pancreatitis due to gallstones. The physician
documents acute pancreatitis without necrosis. What is the correct ICD-10-CM
code?
A) K85.00 – Idiopathic acute pancreatitis without necrosis or infection
B) K85.10 – Biliary acute pancreatitis without necrosis or infection
C) K85.20 – Alcohol-induced acute pancreatitis without necrosis or infection
D) K85.90 – Acute pancreatitis without necrosis or infection, unspecified
Rationale: When acute pancreatitis is due to gallstones (biliary etiology), the
appropriate code is from the biliary category. K85.10 (Biliary acute pancreatitis
without necrosis or infection) is the correct code when there is no necrosis or
infection documented. The coder should not use the unspecified code when a more
specific etiology is documented.
Question 9
A patient is admitted with acute appendicitis with generalized peritonitis. What is
the correct ICD-10-CM code?
A) K35.2 – Acute appendicitis with generalized peritonitis
B) K35.3 – Acute appendicitis with localized peritonitis
C) K35.8 – Acute appendicitis, other and unspecified
D) K35.89 – Acute appendicitis, other
Rationale: ICD-10-CM has combination codes for appendicitis with
peritonitis. K35.2 (Acute appendicitis with generalized peritonitis) is the correct
code for this scenario. K35.3 is for localized peritonitis. K35.8 is used when the
peritonitis is not specified as generalized or localized.
Exam Prep 2026 Updated Practice Questions –
Comprehensive Clinical Documentation Improvement
Review Detailed Explanations – Verified Answers –
Complete Success Workbook
SECTION 1: CLINICAL CODING PRACTICE (15–18% of Exam)
Question 1
A patient is admitted with chest pain and is subsequently diagnosed with acute
myocardial infarction (AMI) of the anterolateral wall. The physician documents
"acute myocardial infarction" without specifying the site. What is the correct ICD-
10-CM code assignment?
A) I21.09 – Acute myocardial infarction, unspecified
B) I21.09 – Acute myocardial infarction, unspecified
C) I21.19 – Acute myocardial infarction, other
D) I21.4 – Non-ST elevation (NSTEMI) myocardial infarction
Rationale: When the physician documents "acute myocardial infarction" without
specifying the site or type (STEMI vs. NSTEMI), the correct code is I21.09 (Acute
myocardial infarction, unspecified). The coder should not assume the site or type
without clear documentation. If the documentation lacks specificity, the CDI
specialist should query the physician for clarification.
Question 2
A patient is admitted with HIV and Pneumocystis jiroveci pneumonia. What is the
correct principal diagnosis?
A) Asymptomatic HIV
B) Pneumonia
C) B20 – HIV disease
D) B20 and B59 – HIV with Pneumocystis pneumonia
,Rationale: When a patient is admitted for an HIV-related condition, the principal
diagnosis should be B20 (HIV disease). The pneumonia is coded as a secondary
diagnosis. The pneumonia is an HIV-related opportunistic infection, and the HIV is
the underlying condition chiefly responsible for the admission.
Question 3
A patient is admitted with congestive heart failure due to hypertension. Which of
the following code assignments is correct?
A) I10, I50.9
B) I11.0, I50.9
C) I11.0 only
D) I50.9 only
Rationale: When a causal relationship is stated ("due to hypertension"), a
combination code is assigned. I11.0 (Hypertensive heart disease with heart failure)
is the combination code, and an additional code (I50.9) identifies the type of heart
failure.
Question 4
A patient is admitted with acute exacerbation of COPD and pneumonia. The
physician documents both conditions as equally contributing to the admission.
What is the correct ICD-10-CM code?
A) J44.1 – COPD with (acute) exacerbation
B) J44.0 – COPD with acute lower respiratory infection
C) J18.9 – Pneumonia, unspecified organism
D) J44.9 – COPD, unspecified
Rationale: When a patient with COPD has an acute exacerbation and pneumonia,
ICD-10-CM guidelines state that the combination code J44.0 (Chronic obstructive
pulmonary disease with acute lower respiratory infection) should be used. This
combination code captures both the COPD exacerbation and the pneumonia, as
pneumonia is a lower respiratory infection.
,Question 5
A patient is admitted with sepsis due to a urinary tract infection (UTI). What is the
correct ICD-10-CM code assignment?
A) A41.9 – Sepsis, unspecified organism
B) N39.0 – Urinary tract infection, site not specified
C) A41.9 with N39.0 – Sepsis due to UTI
D) R65.20 – Severe sepsis without septic shock
Rationale: ICD-10-CM provides combination codes for sepsis due to a specific
organism or source. When sepsis is due to a urinary tract infection, the
combination code should be used rather than coding the conditions separately. The
sepsis code is sequenced as the principal diagnosis, followed by the UTI code.
Question 6
According to ICD-10-CM Official Guidelines, what is the correct coding for
"status asthmaticus"?
A) J45.901 – Unspecified asthma with (acute) exacerbation
B) J45.902 – Unspecified asthma with status asthmaticus
C) J45.909 – Unspecified asthma, uncomplicated
D) J45.998 – Other asthma
Rationale: Status asthmaticus is a specific, severe form of asthma that does not
respond to standard treatment. The correct code is J45.902 (Unspecified asthma
with status asthmaticus). If the type of asthma is specified (e.g., allergic), the more
specific code for that type with status asthmaticus would be used.
Question 7
A patient undergoes a laparoscopic cholecystectomy. What is the correct ICD-10-
PCS root operation?
A) Resection
B) Excision
C) Removal
D) Destruction
, Rationale: In ICD-10-PCS, the root operation Excision is defined as cutting out or
off, without replacement, a portion of a body part. A cholecystectomy involves the
removal of the gallbladder, which is a portion of the biliary
system. Resection would be used if the entire body part were removed.
Question 8
A patient is admitted with acute pancreatitis due to gallstones. The physician
documents acute pancreatitis without necrosis. What is the correct ICD-10-CM
code?
A) K85.00 – Idiopathic acute pancreatitis without necrosis or infection
B) K85.10 – Biliary acute pancreatitis without necrosis or infection
C) K85.20 – Alcohol-induced acute pancreatitis without necrosis or infection
D) K85.90 – Acute pancreatitis without necrosis or infection, unspecified
Rationale: When acute pancreatitis is due to gallstones (biliary etiology), the
appropriate code is from the biliary category. K85.10 (Biliary acute pancreatitis
without necrosis or infection) is the correct code when there is no necrosis or
infection documented. The coder should not use the unspecified code when a more
specific etiology is documented.
Question 9
A patient is admitted with acute appendicitis with generalized peritonitis. What is
the correct ICD-10-CM code?
A) K35.2 – Acute appendicitis with generalized peritonitis
B) K35.3 – Acute appendicitis with localized peritonitis
C) K35.8 – Acute appendicitis, other and unspecified
D) K35.89 – Acute appendicitis, other
Rationale: ICD-10-CM has combination codes for appendicitis with
peritonitis. K35.2 (Acute appendicitis with generalized peritonitis) is the correct
code for this scenario. K35.3 is for localized peritonitis. K35.8 is used when the
peritonitis is not specified as generalized or localized.
