CDIP EXAM 1 & 2 LATEST ACTUAL EXAM 200+
QUESTIONS AND CORRECT DETAILED ANSWERS WITH
RATIONALES||ALREADY GRADED A+
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).
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)
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).
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)
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).
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).
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).
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).
,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).
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).
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)
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)
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).
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.
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 - ANSWER: d The open biopsy is performed
prior to the definitive surgery so that the pathologist can perform a frozen section of
the tissue to determine malignancy. Approaches, suturing, and closure are not coded
separately. Exploratory surgery is not coded when definitive surgery is performed
(Leon-Chisen 2013, 92).
A patient was admitted with diminished responsiveness and hypotension. The
patient has a history of hypertension, CVA, CHF, and asthma. The patient suffered a
cardiac arrest immediately following admission. The documentation within the
record should:
a.List hypotension as first-listed
b.Include the reason for the cardiac arrest
c.Include the date of the previous CVA
d.Type of hypotension - ANSWER: b Instructional notes in ICD-10-CM for cardiac
arrest states "code first underlying condition".
Causes of nonpressure ulcers of the lower limb include:
a.Varicose ulcers
b.Chronic venous hypertension
c.Diabetic ulcer
d.All of the above - ANSWER: d The causes of lower limb ulcers include
Atherosclerosis of lower extremity, Chronic venous hypertension, Diabetic ulcer,
Postphlebitic syndrome, Postthrombotic syndrome, Varicose ulcer, and Other as
specified (AHIMA 2015, 38).
An 82-year-old female was walking and inadvertently twisted an ankle causing a
minor fall. The patient suffered a fracture of the tibia. The patient was treated and
QUESTIONS AND CORRECT DETAILED ANSWERS WITH
RATIONALES||ALREADY GRADED A+
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).
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)
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).
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)
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).
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).
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).
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).
,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).
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).
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)
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)
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).
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.
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 - ANSWER: d The open biopsy is performed
prior to the definitive surgery so that the pathologist can perform a frozen section of
the tissue to determine malignancy. Approaches, suturing, and closure are not coded
separately. Exploratory surgery is not coded when definitive surgery is performed
(Leon-Chisen 2013, 92).
A patient was admitted with diminished responsiveness and hypotension. The
patient has a history of hypertension, CVA, CHF, and asthma. The patient suffered a
cardiac arrest immediately following admission. The documentation within the
record should:
a.List hypotension as first-listed
b.Include the reason for the cardiac arrest
c.Include the date of the previous CVA
d.Type of hypotension - ANSWER: b Instructional notes in ICD-10-CM for cardiac
arrest states "code first underlying condition".
Causes of nonpressure ulcers of the lower limb include:
a.Varicose ulcers
b.Chronic venous hypertension
c.Diabetic ulcer
d.All of the above - ANSWER: d The causes of lower limb ulcers include
Atherosclerosis of lower extremity, Chronic venous hypertension, Diabetic ulcer,
Postphlebitic syndrome, Postthrombotic syndrome, Varicose ulcer, and Other as
specified (AHIMA 2015, 38).
An 82-year-old female was walking and inadvertently twisted an ankle causing a
minor fall. The patient suffered a fracture of the tibia. The patient was treated and
