CDIP EXAM 1 UPDATED QUESTIONS AND CORRECT
ANSWERS
Question:
1. Assign code(s) for the following diagnosis: Conges-tive heart failure due to hypertension. I10
Essential (primary) hypertension I11.9 Hypertensive heart disease without heart fail-ure I11.0
Hypertensive heart disease with heart failure I50.9 Heart failure, unspecified I50.1 Left ventricular
failure I50.20 Unspecified systolic (congestive) heart fail-ure 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 as-signed a combination code when a causal relationship is stated (due to
hyperten-sion) or implied (hyperten-sive). Use an additional code to identify the type of heart failure
in those patients with heart failure (ICD-10-CM Of-ficial 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 lacera-tions together d.One CPT code for the most complex
closure
Answer:
c When multiple wounds are repaired with the same clo-sure type (for example, sim-ple), 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 di-aphragmatic hernia. Assign the ICD-10-PCS
proce-dure code for this surgery. 0BQR4ZZ Repair right diaphragm, percutaneous en-doscopic
approach 0BQROZZ Repair right diaphragm, open approach 0BQS4ZZ Repair left diaphragm,
percutaneous en-doscopic approach 0BQSOZZ Repair left diaphragm, open approach a.0BQR4ZZ
b.0BQR0ZZ c.0BQS4ZZ d.0BQS0ZZ
Answer:
a Surgery is the only treatment for diaphragmat-ic hernias. ICD-10-PCS code 0BQR4ZZ, is used for
laparo-scopic repair of diaphrag-matic hernia (Garvin 2015, 192, 284)
,Question:
5. When trying to determine if documentation is pre-sent to substantiate status asthmaticus, the coder
should review the record for what terms and phras-es?
a.Intractable pneumonia b.Refractory asthma and severe, intractable wheez-ing c.Airway obstruction
relieved by bronchodilators d.Limited but pronounced wheezing
Answer:
b Status asthmaticus is de-fined as continual wheez-ing in spite of therapy (Leon-Chisen 2013, 230).
Question:
6. Gastrointestinal bleeding can manifest as:
a.Hematemesis, which indicates acute upper gas-trointestinal hemorrhage b.Petechia c.Vomiting
d.Constipation, which indicates upper or lower gas-trointestinal hemorrhage
Answer:
a Gastrointestinal bleeding manifests itself in several ways. These are hemateme-sis, 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 pace-makers are single chamber, single chamber rate respon-sive, and dual
chamber. A single chamber uses a sin-gle lead; a dual chamber re-quires two leads, one in the atrium
and one in the ven-tricle. 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 fol-lowed by mechanical ventilation d.Mechanical ventilation
during surgery
Answer:
c Codes for mechanical ven-tilation indicate whether the patient was on mechani-cal ventilation for
less than 24 hours, 24-96 consecutive hours and greater than 96 consecutive hours. The start time for
calculating the du-ration begins with the start time of endotracheal tube in-sertion as the best method,
followed by mechanical ven-tilation or the time that a patient who is on mechan-ical ventilation is
admitted. The time ends with discon-tinuance of mechanical ven-tilation (Leon-Chisen 2013,
239-240).
Question:
9. Abbreviations can be a source of patient safety is-sues due to misinterpretation and
miscommunica-tion. 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 ab-breviations in all
its accredit-ed organizations. To comply, every healthcare organization should strive to limit or
elimi-nate the use of abbreviations by developing an organiza-tionspecific abbreviation list so that
only those abbrevi-ations approved by the or-ganization are used. When more than one meaning for
an approved abbreviation ex-ists, an organization should choose only one meaning or context in
which the abbre-viation 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 char-acter 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
Jor-wic 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 In-dex to identify
manifestation codes as well as to enclose synonyms, alternative word-ing or explanatory phrases.
(ICD-10-CM Official Guide-lines for Coding and Report-ing 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 as-sign a more specific code, an unspecified
code is assigned (ICD-10-CM Official Guide-lines for Coding and Report-ing 2016b, 10)
Question:
13. A 30-year-old cerebral palsy patient was admitted with acute bronchitis, possible pneumonia. In
re-viewing 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 addition-ally 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 in-creased specificity.
ANSWERS
Question:
1. Assign code(s) for the following diagnosis: Conges-tive heart failure due to hypertension. I10
Essential (primary) hypertension I11.9 Hypertensive heart disease without heart fail-ure I11.0
Hypertensive heart disease with heart failure I50.9 Heart failure, unspecified I50.1 Left ventricular
failure I50.20 Unspecified systolic (congestive) heart fail-ure 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 as-signed a combination code when a causal relationship is stated (due to
hyperten-sion) or implied (hyperten-sive). Use an additional code to identify the type of heart failure
in those patients with heart failure (ICD-10-CM Of-ficial 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 lacera-tions together d.One CPT code for the most complex
closure
Answer:
c When multiple wounds are repaired with the same clo-sure type (for example, sim-ple), 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 di-aphragmatic hernia. Assign the ICD-10-PCS
proce-dure code for this surgery. 0BQR4ZZ Repair right diaphragm, percutaneous en-doscopic
approach 0BQROZZ Repair right diaphragm, open approach 0BQS4ZZ Repair left diaphragm,
percutaneous en-doscopic approach 0BQSOZZ Repair left diaphragm, open approach a.0BQR4ZZ
b.0BQR0ZZ c.0BQS4ZZ d.0BQS0ZZ
Answer:
a Surgery is the only treatment for diaphragmat-ic hernias. ICD-10-PCS code 0BQR4ZZ, is used for
laparo-scopic repair of diaphrag-matic hernia (Garvin 2015, 192, 284)
,Question:
5. When trying to determine if documentation is pre-sent to substantiate status asthmaticus, the coder
should review the record for what terms and phras-es?
a.Intractable pneumonia b.Refractory asthma and severe, intractable wheez-ing c.Airway obstruction
relieved by bronchodilators d.Limited but pronounced wheezing
Answer:
b Status asthmaticus is de-fined as continual wheez-ing in spite of therapy (Leon-Chisen 2013, 230).
Question:
6. Gastrointestinal bleeding can manifest as:
a.Hematemesis, which indicates acute upper gas-trointestinal hemorrhage b.Petechia c.Vomiting
d.Constipation, which indicates upper or lower gas-trointestinal hemorrhage
Answer:
a Gastrointestinal bleeding manifests itself in several ways. These are hemateme-sis, 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 pace-makers are single chamber, single chamber rate respon-sive, and dual
chamber. A single chamber uses a sin-gle lead; a dual chamber re-quires two leads, one in the atrium
and one in the ven-tricle. 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 fol-lowed by mechanical ventilation d.Mechanical ventilation
during surgery
Answer:
c Codes for mechanical ven-tilation indicate whether the patient was on mechani-cal ventilation for
less than 24 hours, 24-96 consecutive hours and greater than 96 consecutive hours. The start time for
calculating the du-ration begins with the start time of endotracheal tube in-sertion as the best method,
followed by mechanical ven-tilation or the time that a patient who is on mechan-ical ventilation is
admitted. The time ends with discon-tinuance of mechanical ven-tilation (Leon-Chisen 2013,
239-240).
Question:
9. Abbreviations can be a source of patient safety is-sues due to misinterpretation and
miscommunica-tion. 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 ab-breviations in all
its accredit-ed organizations. To comply, every healthcare organization should strive to limit or
elimi-nate the use of abbreviations by developing an organiza-tionspecific abbreviation list so that
only those abbrevi-ations approved by the or-ganization are used. When more than one meaning for
an approved abbreviation ex-ists, an organization should choose only one meaning or context in
which the abbre-viation 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 char-acter 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
Jor-wic 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 In-dex to identify
manifestation codes as well as to enclose synonyms, alternative word-ing or explanatory phrases.
(ICD-10-CM Official Guide-lines for Coding and Report-ing 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 as-sign a more specific code, an unspecified
code is assigned (ICD-10-CM Official Guide-lines for Coding and Report-ing 2016b, 10)
Question:
13. A 30-year-old cerebral palsy patient was admitted with acute bronchitis, possible pneumonia. In
re-viewing 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 addition-ally 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 in-creased specificity.
