CDIP Domain 1: Clinical Coding Practice
Exam Questions with Complete Answers
Coding Clinic - Answer-Valuable reference tool for coders that is published by AHA
each quarter
CPT - Answer-Current Procedural Terminology
MS-DRGs - Answer-Medicare Severity-Diagnosis Related Groups
CPT Assistant - Answer-Monthly publication by the AMA that provides coding advice for
CPT coding scenarios
Encoder Nosology - Answer-Provides coding professionals from the encoder company
that are available to help answer tough coding questions
History & Physical - Answer-Provides the initial chief complaint and initial impressions of
the provider when the patient is first admitted. It also has a comprehensive physical
review of the patient's body systems and vital signs, and provides the initial treatment
plan, medications, and tests that are being ordered to treat the patient.
Progress Notes - Answer-Provide information about what is going on with the patient on
a day-to-day basis; they should include the diagnoses that are being treated as well as
any information about any changes in the patient's well-being and tests/procedures
being performed.
Operative and Pathology Reports - Answer-Summarize the invasive procedures
performed and any samples that are removed from the patient's body
Pathology report - Answer-Provides detailed information from the pathologist of the
facility as to the status of the tissues or organs removed from the patient's body
Encoder - Answer-Specialty software used to facilitate the assignment of diagnostic and
procedural codes according to the rules of the coding system
What is the value of utilizing coding software? - Answer-It facilitates accurate coding by
providing links to coding resources, groups diagnosis and procedure codes to the
correct MS-DRG, and provides edits with additional information for the coder to consider
when placing codes into the encoder
Principal diagnosis - Answer-Diagnosis that, after study, is the reason for the patient's
admission to the hospital.
Exam Questions with Complete Answers
Coding Clinic - Answer-Valuable reference tool for coders that is published by AHA
each quarter
CPT - Answer-Current Procedural Terminology
MS-DRGs - Answer-Medicare Severity-Diagnosis Related Groups
CPT Assistant - Answer-Monthly publication by the AMA that provides coding advice for
CPT coding scenarios
Encoder Nosology - Answer-Provides coding professionals from the encoder company
that are available to help answer tough coding questions
History & Physical - Answer-Provides the initial chief complaint and initial impressions of
the provider when the patient is first admitted. It also has a comprehensive physical
review of the patient's body systems and vital signs, and provides the initial treatment
plan, medications, and tests that are being ordered to treat the patient.
Progress Notes - Answer-Provide information about what is going on with the patient on
a day-to-day basis; they should include the diagnoses that are being treated as well as
any information about any changes in the patient's well-being and tests/procedures
being performed.
Operative and Pathology Reports - Answer-Summarize the invasive procedures
performed and any samples that are removed from the patient's body
Pathology report - Answer-Provides detailed information from the pathologist of the
facility as to the status of the tissues or organs removed from the patient's body
Encoder - Answer-Specialty software used to facilitate the assignment of diagnostic and
procedural codes according to the rules of the coding system
What is the value of utilizing coding software? - Answer-It facilitates accurate coding by
providing links to coding resources, groups diagnosis and procedure codes to the
correct MS-DRG, and provides edits with additional information for the coder to consider
when placing codes into the encoder
Principal diagnosis - Answer-Diagnosis that, after study, is the reason for the patient's
admission to the hospital.
