CDIP EXAM 1 UPDATED QUESTIONS AND
CORRECT ANSWERS
Question:
1. Assign code(s) for the following diagnosis: Congestive heart failure due to hypertension. I10 Essential
(primary) hypertension I11.9 Hypertensive heart disease without heart failure I11.0 Hypertensive heart
disease with heart failure I50.9 Heart failure, unspecified I50.1 Left ventricular failure I50.20 Unspecified
systolic (congestive) heart failure I50.21 Acute systolic (congestive) heart failure I50.22 Chronic systolic
(congestive) heart failure I50.23 Acute on chronic systolic (congestive) heart failure
a.I10, I50.9
b.I11.0
c.I50.23, I10
d.I11.0, I50.9
Answer:
d Heart conditions are assigned a combination code when a causal relationship is stated (due to
hypertension) or implied (hypertensive). Use an additional code to identify the type of heart failure in those
patients with heart failure (ICD-10-CM Official Guidelines for Coding and Reporting 2016b, 41).
Question:
2. Assign the best answer to complete the following sentence. The CPT codes for treatment of fractures:
a.Use the terminology "manipulation" rather than "reduction" of fracture
b.Include internal fixation in all codes
c.Do not include application of cast
d.Do not differentiate between open and closed treatment; CPT only specifies the site of the fracture
Answer:
a Manipulation refers to the attempted reduction or restoration of a dislocated joint or fracture (Smith
2015,
84)
Question:
3. In CPT, if a patient has two lacerations of the arm that are repaired with simple closures, the coder
would assign:
a.Two CPT codes expressing each laceration repair
b.One CPT code for the largest laceration
c.One CPT code, adding the lengths of the lacerations together
d.One CPT code for the most complex closure
Answer:
c When multiple wounds are repaired with the same closure type (for example, simple), lengths of the
wounds in the same classification and from all anatomical sites that are grouped together into the same
code descriptor should be added together (Smith 2015, 67).
,Question:
4. Patient admitted for laparoscopic repair of right diaphragmatic hernia. Assign the ICD-10-PCS
procedure code for this surgery. 0BQR4ZZ Repair right diaphragm, percutaneous endoscopic approach
0BQROZZ Repair right diaphragm, open approach 0BQS4ZZ Repair left diaphragm, percutaneous
endoscopic approach 0BQSOZZ Repair left diaphragm, open approach
a.0BQR4ZZ
b.0BQR0ZZ
c.0BQS4ZZ
d.0BQS0ZZ
Answer:
a Surgery is the only treatment for diaphragmatic hernias. ICD-10-PCS code 0BQR4ZZ, is used for
laparoscopic repair of diaphragmatic hernia (Garvin 2015, 192, 284)
Question:
5. 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
Answer:
b Status asthmaticus is defined as continual wheezing in spite of therapy (Leon-Chisen 2013, 230).
Question:
6. Gastrointestinal bleeding can manifest as:
a.Hematemesis, which indicates acute upper gastrointestinal hemorrhage
b.Petechia
c.Vomiting
d.Constipation, which indicates upper or lower gastrointestinal hemorrhage
Answer:
a Gastrointestinal bleeding manifests itself in several ways. These are hematemesis, melena, occult
bleeding, hematochezia (Leon-Chisen 2013, 244).
Question:
7. Which types of pacemaker devices have a unique ICD-10-PCS code.
a.Dual chamber rate responsive
b.Single chamber, single chamber rate responsive, and dual chamber
c.Multiple chamber
d.Multiple chamber rate responsive
Answer:
b The three types of pacemakers are single chamber, single chamber rate responsive, and dual chamber. A
single chamber uses a single lead; a dual chamber requires two leads, one in the atrium and one in the
ventricle. The leads should also be coded (Leon-Chisen 2013, 416-418).
,Question:
8. Mechanical ventilation codes require consideration of which of the following?
a.The time when a tracheal tube is inserted
b.The replacement of an endotracheal tube
c.The start time of endotracheal tube insertion followed by mechanical ventilation
d.Mechanical ventilation during surgery
Answer:
c Codes for mechanical ventilation indicate whether the patient was on mechanical ventilation for less than
24 hours, 24-96 consecutive hours and greater than 96 consecutive hours. The start time for calculating the
duration begins with the start time of endotracheal tube insertion as the best method, followed by
mechanical ventilation or the time that a patient who is on mechanical ventilation is admitted. The time
ends with discontinuance of mechanical ventilation (Leon-Chisen 2013, 239-240).
Question:
9. Abbreviations can be a source of patient safety issues due to misinterpretation and miscommunication.
Abbreviations in the health record:
a.Are not permitted by Joint Commission standards
b.Should have only one meaning
c.Enhance patient safety
d.Are critical to an electronic health record system
Answer:
b The Joint Commission has established a cautious quality approach to the use of abbreviations in all its
accredited organizations. To comply, every healthcare organization should strive to limit or eliminate the
use of abbreviations by developing an organizationspecific abbreviation list so that only those
abbreviations approved by the organization are used. When more than one meaning for an approved
abbreviation exists, an organization should choose only one meaning or context in which the abbreviation
is to be used (Shaw and Carter 2014; Brodnik et al. 2012, 180-181).
Question:
10. In ICD-10-PCS, what value is used if there is a character that does not apply to a given code?
a.X
b.Z
c.0
d.-
Answer:
b All ICD-10-PCS codes must be seven characters, and a character cannot be left blank. If a value does not
exist for a given character, the Z is used as the value (Shaw and Carter 2014; Kuehn and Jorwic 2013, 5).
Question:
11. Which symbol of punctuation is used in the Tabular List to enclose synonyms, alternative wording, or
explanatory phrases?
a.Parentheses
b.Brackets
c.Colon
d.Comma
, Answer:
a Punctuation is widely used in coding. Brackets are used in the Alphabetic Index to identify manifestation
codes as well as to enclose synonyms, alternative wording or explanatory phrases. (ICD-10-CM Official
Guidelines for Coding and Reporting 2016b, 8)
Question:
12. When the documentation in the medical record is insufficient to assign a more specific code, a _______
code is assigned.
a.MCC
b.CC
c.NOS
d.Unspecified
Answer:
d When documentation in the record is not available to assign a more specific code, an unspecified code is
assigned (ICD-10-CM Official Guidelines for Coding and Reporting 2016b, 10)
Question:
13. A 30-year-old cerebral palsy patient was admitted with acute bronchitis, possible pneumonia. In
reviewing the diagnoses below what additionally will impact the patient's ICD-10 code assignment.
a.Spasticity
b.Quadriplegia
c.Both A and B
d.None of the above
Answer:
c ICD-10 Cerebral palsy and other paralytic syndromes (G80-G83) has additional specificity for spasticity
as well as state of paralysis if any (AHIMA 2015, 23).
Question:
14. A 90-year-old female was determined to have a CVA with hemorrhage. The cause of the hemorrhage
was determined to be an embolism. What additionally could impact code assignment for the embolism
code?
a.Hematemesis
b.Hypertension
c.Site of the hemorrhage
d.Seizure
Answer:
c ICD-10 includes the site of the of the hemorrhage for increased specificity.
Question:
15. If a patient undergoes a biopsy immediately before the definitive surgery for a frozen section, how
should this be coded with ICD-10-PCS codes?
a.The approach to the definitive surgery
b.Suture method
c.Exploratory surgery
d.Open biopsy and definitive surgery
CORRECT ANSWERS
Question:
1. Assign code(s) for the following diagnosis: Congestive heart failure due to hypertension. I10 Essential
(primary) hypertension I11.9 Hypertensive heart disease without heart failure I11.0 Hypertensive heart
disease with heart failure I50.9 Heart failure, unspecified I50.1 Left ventricular failure I50.20 Unspecified
systolic (congestive) heart failure I50.21 Acute systolic (congestive) heart failure I50.22 Chronic systolic
(congestive) heart failure I50.23 Acute on chronic systolic (congestive) heart failure
a.I10, I50.9
b.I11.0
c.I50.23, I10
d.I11.0, I50.9
Answer:
d Heart conditions are assigned a combination code when a causal relationship is stated (due to
hypertension) or implied (hypertensive). Use an additional code to identify the type of heart failure in those
patients with heart failure (ICD-10-CM Official Guidelines for Coding and Reporting 2016b, 41).
Question:
2. Assign the best answer to complete the following sentence. The CPT codes for treatment of fractures:
a.Use the terminology "manipulation" rather than "reduction" of fracture
b.Include internal fixation in all codes
c.Do not include application of cast
d.Do not differentiate between open and closed treatment; CPT only specifies the site of the fracture
Answer:
a Manipulation refers to the attempted reduction or restoration of a dislocated joint or fracture (Smith
2015,
84)
Question:
3. In CPT, if a patient has two lacerations of the arm that are repaired with simple closures, the coder
would assign:
a.Two CPT codes expressing each laceration repair
b.One CPT code for the largest laceration
c.One CPT code, adding the lengths of the lacerations together
d.One CPT code for the most complex closure
Answer:
c When multiple wounds are repaired with the same closure type (for example, simple), lengths of the
wounds in the same classification and from all anatomical sites that are grouped together into the same
code descriptor should be added together (Smith 2015, 67).
,Question:
4. Patient admitted for laparoscopic repair of right diaphragmatic hernia. Assign the ICD-10-PCS
procedure code for this surgery. 0BQR4ZZ Repair right diaphragm, percutaneous endoscopic approach
0BQROZZ Repair right diaphragm, open approach 0BQS4ZZ Repair left diaphragm, percutaneous
endoscopic approach 0BQSOZZ Repair left diaphragm, open approach
a.0BQR4ZZ
b.0BQR0ZZ
c.0BQS4ZZ
d.0BQS0ZZ
Answer:
a Surgery is the only treatment for diaphragmatic hernias. ICD-10-PCS code 0BQR4ZZ, is used for
laparoscopic repair of diaphragmatic hernia (Garvin 2015, 192, 284)
Question:
5. 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
Answer:
b Status asthmaticus is defined as continual wheezing in spite of therapy (Leon-Chisen 2013, 230).
Question:
6. Gastrointestinal bleeding can manifest as:
a.Hematemesis, which indicates acute upper gastrointestinal hemorrhage
b.Petechia
c.Vomiting
d.Constipation, which indicates upper or lower gastrointestinal hemorrhage
Answer:
a Gastrointestinal bleeding manifests itself in several ways. These are hematemesis, melena, occult
bleeding, hematochezia (Leon-Chisen 2013, 244).
Question:
7. Which types of pacemaker devices have a unique ICD-10-PCS code.
a.Dual chamber rate responsive
b.Single chamber, single chamber rate responsive, and dual chamber
c.Multiple chamber
d.Multiple chamber rate responsive
Answer:
b The three types of pacemakers are single chamber, single chamber rate responsive, and dual chamber. A
single chamber uses a single lead; a dual chamber requires two leads, one in the atrium and one in the
ventricle. The leads should also be coded (Leon-Chisen 2013, 416-418).
,Question:
8. Mechanical ventilation codes require consideration of which of the following?
a.The time when a tracheal tube is inserted
b.The replacement of an endotracheal tube
c.The start time of endotracheal tube insertion followed by mechanical ventilation
d.Mechanical ventilation during surgery
Answer:
c Codes for mechanical ventilation indicate whether the patient was on mechanical ventilation for less than
24 hours, 24-96 consecutive hours and greater than 96 consecutive hours. The start time for calculating the
duration begins with the start time of endotracheal tube insertion as the best method, followed by
mechanical ventilation or the time that a patient who is on mechanical ventilation is admitted. The time
ends with discontinuance of mechanical ventilation (Leon-Chisen 2013, 239-240).
Question:
9. Abbreviations can be a source of patient safety issues due to misinterpretation and miscommunication.
Abbreviations in the health record:
a.Are not permitted by Joint Commission standards
b.Should have only one meaning
c.Enhance patient safety
d.Are critical to an electronic health record system
Answer:
b The Joint Commission has established a cautious quality approach to the use of abbreviations in all its
accredited organizations. To comply, every healthcare organization should strive to limit or eliminate the
use of abbreviations by developing an organizationspecific abbreviation list so that only those
abbreviations approved by the organization are used. When more than one meaning for an approved
abbreviation exists, an organization should choose only one meaning or context in which the abbreviation
is to be used (Shaw and Carter 2014; Brodnik et al. 2012, 180-181).
Question:
10. In ICD-10-PCS, what value is used if there is a character that does not apply to a given code?
a.X
b.Z
c.0
d.-
Answer:
b All ICD-10-PCS codes must be seven characters, and a character cannot be left blank. If a value does not
exist for a given character, the Z is used as the value (Shaw and Carter 2014; Kuehn and Jorwic 2013, 5).
Question:
11. Which symbol of punctuation is used in the Tabular List to enclose synonyms, alternative wording, or
explanatory phrases?
a.Parentheses
b.Brackets
c.Colon
d.Comma
, Answer:
a Punctuation is widely used in coding. Brackets are used in the Alphabetic Index to identify manifestation
codes as well as to enclose synonyms, alternative wording or explanatory phrases. (ICD-10-CM Official
Guidelines for Coding and Reporting 2016b, 8)
Question:
12. When the documentation in the medical record is insufficient to assign a more specific code, a _______
code is assigned.
a.MCC
b.CC
c.NOS
d.Unspecified
Answer:
d When documentation in the record is not available to assign a more specific code, an unspecified code is
assigned (ICD-10-CM Official Guidelines for Coding and Reporting 2016b, 10)
Question:
13. A 30-year-old cerebral palsy patient was admitted with acute bronchitis, possible pneumonia. In
reviewing the diagnoses below what additionally will impact the patient's ICD-10 code assignment.
a.Spasticity
b.Quadriplegia
c.Both A and B
d.None of the above
Answer:
c ICD-10 Cerebral palsy and other paralytic syndromes (G80-G83) has additional specificity for spasticity
as well as state of paralysis if any (AHIMA 2015, 23).
Question:
14. A 90-year-old female was determined to have a CVA with hemorrhage. The cause of the hemorrhage
was determined to be an embolism. What additionally could impact code assignment for the embolism
code?
a.Hematemesis
b.Hypertension
c.Site of the hemorrhage
d.Seizure
Answer:
c ICD-10 includes the site of the of the hemorrhage for increased specificity.
Question:
15. If a patient undergoes a biopsy immediately before the definitive surgery for a frozen section, how
should this be coded with ICD-10-PCS codes?
a.The approach to the definitive surgery
b.Suture method
c.Exploratory surgery
d.Open biopsy and definitive surgery
