CDIP EXAM Domain 1 ACTUAL
QUESTIONS AND CORRECT ANSWERS
Principal diagnosis (Inpatient) - CORRECT ANSWERS The disease
present on admission that received treatment or evaluation during the hospital
stay or the reason established after a study to be responsible for the patient's
admission
Secondary Diagnosis - CORRECT ANSWERS A statement of those
conditions coexisting during a hospital episode that affect treatment received or
length of stay
Where to find the pertinent diagnosis - CORRECT ANSWERS 1. H&P
2. Progress Notes
3. Clinical Notes
4. Operative/Pathology Report
5. Procedure Notes
6. Lab/Radiology Findings
7. Discharge Summary
7 Characteristics of High Quality Clinical Documentation - CORRECT
ANSWERS Clear
Consistent
Complete
Precise
Legible
Timely
Reliable
,first-listed diagnosis - CORRECT ANSWERS in the outpatient setting,
the primary diagnosis is the main reason for the visit. it is usually the diagnosis
taking the majority of resources for the visit
CC - CORRECT ANSWERS conditions and comorbidities
MCC - CORRECT ANSWERS Major Conditions and Comorbidities
Perspective Payment Systems - CORRECT ANSWERS Predetermined
payment based on service provided; began as inpatient but moved to different
healthcare areas
MSDRG - CORRECT ANSWERS Medicare Severity Diagnosis Related
Groups
MDC - CORRECT ANSWERS Major Diagnostic Category - represents
the body systems treated by medicine. (There are 25 MDCs). Examples: 1)
diseases and disorders of the nervous system, 2) diseases and disorders of the
eye, 3) infectious and parasitic diseases, 4) HIV, 5) endocrine & metabolic
disorders, 6) pregnancy, childbirth, and the puerperium, etc...
ICD-10-CM - CORRECT ANSWERS International Classification of
Diseases, 10th Revision, Clinical Modification
ICD-10 Procedure Coding System (ICD-10-PCS) - CORRECT ANSWERS
- a system of medical classification used for procedural codes - for
hospital inpatient use only
Encoder - CORRECT ANSWERS Specialty software used to facilitate
the assignment of diagnostic and procedural codes according to the rules of the
coding system
, Why use coding software? - CORRECT ANSWERS Accurate coding
Productivity
Grouping
Edits
Resources
Complication - CORRECT ANSWERS Condition arising during hospital
stay that prolongs length of stay by at least 1 day in approx. 75% of cases
Comorbidity - CORRECT ANSWERS A pre-existing condition which
because of its presence with the principal diagnosis will increase the length of
stay by at least 1 day in approx. 75% of cases
APR-DRG - CORRECT ANSWERS All Patient Refined Diagnosis-
Related Groups
Severity of Illness (SOI) - CORRECT ANSWERS extent of
physiological decompensation or organ system loss of function.
Risk of Mortality (ROM) - CORRECT ANSWERS the likelihood of
dying.
Four levels to SOI and ROM - CORRECT ANSWERS 1 = Minor
2 = Moderate
3 = Major
4 = Severe
QUESTIONS AND CORRECT ANSWERS
Principal diagnosis (Inpatient) - CORRECT ANSWERS The disease
present on admission that received treatment or evaluation during the hospital
stay or the reason established after a study to be responsible for the patient's
admission
Secondary Diagnosis - CORRECT ANSWERS A statement of those
conditions coexisting during a hospital episode that affect treatment received or
length of stay
Where to find the pertinent diagnosis - CORRECT ANSWERS 1. H&P
2. Progress Notes
3. Clinical Notes
4. Operative/Pathology Report
5. Procedure Notes
6. Lab/Radiology Findings
7. Discharge Summary
7 Characteristics of High Quality Clinical Documentation - CORRECT
ANSWERS Clear
Consistent
Complete
Precise
Legible
Timely
Reliable
,first-listed diagnosis - CORRECT ANSWERS in the outpatient setting,
the primary diagnosis is the main reason for the visit. it is usually the diagnosis
taking the majority of resources for the visit
CC - CORRECT ANSWERS conditions and comorbidities
MCC - CORRECT ANSWERS Major Conditions and Comorbidities
Perspective Payment Systems - CORRECT ANSWERS Predetermined
payment based on service provided; began as inpatient but moved to different
healthcare areas
MSDRG - CORRECT ANSWERS Medicare Severity Diagnosis Related
Groups
MDC - CORRECT ANSWERS Major Diagnostic Category - represents
the body systems treated by medicine. (There are 25 MDCs). Examples: 1)
diseases and disorders of the nervous system, 2) diseases and disorders of the
eye, 3) infectious and parasitic diseases, 4) HIV, 5) endocrine & metabolic
disorders, 6) pregnancy, childbirth, and the puerperium, etc...
ICD-10-CM - CORRECT ANSWERS International Classification of
Diseases, 10th Revision, Clinical Modification
ICD-10 Procedure Coding System (ICD-10-PCS) - CORRECT ANSWERS
- a system of medical classification used for procedural codes - for
hospital inpatient use only
Encoder - CORRECT ANSWERS Specialty software used to facilitate
the assignment of diagnostic and procedural codes according to the rules of the
coding system
, Why use coding software? - CORRECT ANSWERS Accurate coding
Productivity
Grouping
Edits
Resources
Complication - CORRECT ANSWERS Condition arising during hospital
stay that prolongs length of stay by at least 1 day in approx. 75% of cases
Comorbidity - CORRECT ANSWERS A pre-existing condition which
because of its presence with the principal diagnosis will increase the length of
stay by at least 1 day in approx. 75% of cases
APR-DRG - CORRECT ANSWERS All Patient Refined Diagnosis-
Related Groups
Severity of Illness (SOI) - CORRECT ANSWERS extent of
physiological decompensation or organ system loss of function.
Risk of Mortality (ROM) - CORRECT ANSWERS the likelihood of
dying.
Four levels to SOI and ROM - CORRECT ANSWERS 1 = Minor
2 = Moderate
3 = Major
4 = Severe
