CDIP Practice Exam 2 Test Bank:
Verified Q&A Study Guide for
2025/2026 - Master the Material &
Pass Your Certification First Try
A physician admits a patient with shortness of breath and chest pain, then treats the patient
with Lasix, oxygen, and Theophylline. The physician's final documented diagnosis for the
patient is acute exacerbation of COPD. What is missing from this diagnosis that would make it
reliable information in the treatment of this patient?
a.No additional information is needed.
b.The type of COPD
c.The reason the patient was treated with Lasix
d.The reason for the Theophylline
If the physician does not document the diagnosis, the coding professional cannot assume the
patient has a diagnosis based solely on
a.An abnormal lab finding
b.Abnormal pathology reports
c.Both A and B
d.None of the above
c The coder cannot assume diagnoses on abnormal findings such as lab reports. Abnormal
findings (laboratory, X-ray, pathologic, and other diagnostic results) are not coded and reported
unless the physician indicates their clinical significance. If the findings are outside the normal
range and the physician has ordered other tests to evaluate the condition or prescribed
Page 1 of 35
,treatment, it is appropriate to ask the physician whether the diagnosis should be added (AHA
1990, 15).
A physician query may be appropriate in which of the following instances?
a.Diagnosis of diastolic heart failure noted in the progress notes and echocardiogram showing
systolic dysfunction with cardiomegaly
b.Discharge summary indicates chronic pancreatitis but the progress notes document acute
pancreatitis throughout the stay
c.A colonic mass was removed via colonoscopy and sent to pathology. The diagnosis of
malignant carcinoma of the colon mass when pathology states no malignancy
d.All of the above
d A query may be appropriate because the clinical information or clinical picture does not
appear to support the documentation of a condition or procedure. In situations in which the
provider's documented diagnosis does not appear to be supported by clinical findings, a
healthcare entity's policies can provide guidance on a process for addressing the issue without
querying the attending physician (Shaw and Carter 2014; Schraffenberger and Kuehn 2011,
348).
Mrs. Spade was admitted with pain, redness, and exudate noted of the right knee. The patient
had a replacement last week of the right knee. The patient was taken back to the OR and was
noted to have loosening noted on brief operative note. Replacement was performed. The
physician documented osteoarthritis of the knee. The diagnosis query that could better reflect
the severity of illness and resources utilized for this patient could be
a.Mechanical complication of internal fixation device
b.Septic knee
c.Traumatic knee injury
d.Fracture of knee joint
a With findings of pain, redness, and exudate with prior replacement last week of the right knee
with loosening noted, query could be warranted for complication of an internal fixation device
to validate loosening from bone.
•Is conflicting, imprecise, incomplete, illegible, ambiguous, or inconsistent
•Describes or is associated with clinical indicators without a definitive relationship to an
underlying diagnosis
•Includes clinical indicators, diagnostic evaluation, or treatment not related to a specific
condition or procedure
•Provides a diagnosis without underlying clinical validation
•Is unclear for present on admission indicator assignment (AHIMA 2013a, 1)
Page 2 of 35
,Mr. Ace was seen in the outpatient clinic and treated with Z-Max for bronchitis. The patient
presented to the ED with tachycardia, cough, fever, and green sputum. Chest x-ray was
performed with left lower lobe infiltrate. The patient was admitted with bronchitis. Sputum
cultures were obtained in the ED as it was discovered the patient never filled the Z-Max
prescription. Sputum showed Staph and the patient was started on Vancomycin. The patient
was discharged with a diagnosis of acute bronchitis. The diagnosis query that could better
reflect the severity of illness and resources utilized for this patient and is clinically supported
would be
a.Acute or chronic bronchitis
b.Sepsis
c.Pneumonia
d.Sepsis and pneumonia
c Based on failed outpatient treatment the clinical findings of tachycardia, cough, fever, and
green-sputum, chest x-ray was performed with left lower lobe infiltrate, and positive sputum
cultures, query could be warranted for pneumonia.
•Is conflicting, imprecise, incomplete, illegible, ambiguous, or inconsistent
•Describes or is associated with clinical indicators without a definitive relationship to an
underlying diagnosis
•Includes clinical indicators, diagnostic evaluation, and/or treatment not related to a specific
condition or procedure
•Provides a diagnosis without underlying clinical validation
•Is unclear for present on admission indicator assignment
A patient was admitted with a CVA due to subarachnoid hemorrhage. On day two, it was
noted the patient had an elevated BUN and creatinine 3 times the baseline with anuria. The
physician documents acute kidney injury or failure. This diagnosis may warrant
a.Query for acute renal failure
b.Query for present on admission
c.No query warranted
d.Query for CVA
c No query warranted. There is no conflicting, unclear information.
•Is conflicting, imprecise, incomplete, illegible, ambiguous, or inconsistent
•Describes or is associated with clinical indicators without a definitive relationship to an
underlying diagnosis
•Includes clinical indicators, diagnostic evaluation, and/or treatment not related to a specific
condition or procedure
Page 3 of 35
, •Provides a diagnosis without underlying clinical validation
•Is unclear for present on admission indicator assignment
A new CDS performed her daily reviews and utilized a discharge summary performed by the
resident. During reconciliation of reviews, it was noted that the attending physician refused to
sign the discharge summary and dictated an addendum. The CDS received a note from the
department manager which stated _______ is responsible for the content of the record as the
primary physician
a.Attending physician
b.Head nurse
c.Consulting physician
d.Admitting nurse
a The physician principally responsible for the patient's hospital care generally dictates the
discharge summary. However, a resident, physician assistant, or nurse practitioner who is being
supervised by the attending physician may complete this task. Regardless of who documents it,
the attending physician is responsible for the content and quality of the summary and must date
and sign it (Shaw and Carter 2014; Fahrenholz and Russo 2013, 284).
The following conditions are considered _________: ABO incompatibility, falls and trauma, air
embolism, stage III and IV ulcers
a.PSIs (Patient safety indicators)
b.POAs (Present on admission indicators)
c.HACs (Hospital acquired conditions)
d.Acute and chronic conditions
c As part of the Inpatient Prospective Payment System (IPPS) Fiscal Year (FY) 2009 Final Rule,
CMS included 10 categories of conditions that were selected for as Hospital Acquired
Conditions. Currently there are 14 categories which include Air Embolism, Blood Incompatibility,
Stage III and IV Pressure Ulcers, and Falls and Trauma. See
https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/HospitalAcqCond/Hospital-
Acquired_Conditions.html for full listing (CMS 2013).
The CDI manager at Star Hospital has been concerned about the hospital quality ratings over
the past 2 years. She has been focused on educating physicians on documentation and
working with CDS staff on hospital acquired conditions, MCC/CC capture. She may also want
to educate regarding which area below to increase quality score:
a.The principal diagnosis
b.The principal procedure
Page 4 of 35
Verified Q&A Study Guide for
2025/2026 - Master the Material &
Pass Your Certification First Try
A physician admits a patient with shortness of breath and chest pain, then treats the patient
with Lasix, oxygen, and Theophylline. The physician's final documented diagnosis for the
patient is acute exacerbation of COPD. What is missing from this diagnosis that would make it
reliable information in the treatment of this patient?
a.No additional information is needed.
b.The type of COPD
c.The reason the patient was treated with Lasix
d.The reason for the Theophylline
If the physician does not document the diagnosis, the coding professional cannot assume the
patient has a diagnosis based solely on
a.An abnormal lab finding
b.Abnormal pathology reports
c.Both A and B
d.None of the above
c The coder cannot assume diagnoses on abnormal findings such as lab reports. Abnormal
findings (laboratory, X-ray, pathologic, and other diagnostic results) are not coded and reported
unless the physician indicates their clinical significance. If the findings are outside the normal
range and the physician has ordered other tests to evaluate the condition or prescribed
Page 1 of 35
,treatment, it is appropriate to ask the physician whether the diagnosis should be added (AHA
1990, 15).
A physician query may be appropriate in which of the following instances?
a.Diagnosis of diastolic heart failure noted in the progress notes and echocardiogram showing
systolic dysfunction with cardiomegaly
b.Discharge summary indicates chronic pancreatitis but the progress notes document acute
pancreatitis throughout the stay
c.A colonic mass was removed via colonoscopy and sent to pathology. The diagnosis of
malignant carcinoma of the colon mass when pathology states no malignancy
d.All of the above
d A query may be appropriate because the clinical information or clinical picture does not
appear to support the documentation of a condition or procedure. In situations in which the
provider's documented diagnosis does not appear to be supported by clinical findings, a
healthcare entity's policies can provide guidance on a process for addressing the issue without
querying the attending physician (Shaw and Carter 2014; Schraffenberger and Kuehn 2011,
348).
Mrs. Spade was admitted with pain, redness, and exudate noted of the right knee. The patient
had a replacement last week of the right knee. The patient was taken back to the OR and was
noted to have loosening noted on brief operative note. Replacement was performed. The
physician documented osteoarthritis of the knee. The diagnosis query that could better reflect
the severity of illness and resources utilized for this patient could be
a.Mechanical complication of internal fixation device
b.Septic knee
c.Traumatic knee injury
d.Fracture of knee joint
a With findings of pain, redness, and exudate with prior replacement last week of the right knee
with loosening noted, query could be warranted for complication of an internal fixation device
to validate loosening from bone.
•Is conflicting, imprecise, incomplete, illegible, ambiguous, or inconsistent
•Describes or is associated with clinical indicators without a definitive relationship to an
underlying diagnosis
•Includes clinical indicators, diagnostic evaluation, or treatment not related to a specific
condition or procedure
•Provides a diagnosis without underlying clinical validation
•Is unclear for present on admission indicator assignment (AHIMA 2013a, 1)
Page 2 of 35
,Mr. Ace was seen in the outpatient clinic and treated with Z-Max for bronchitis. The patient
presented to the ED with tachycardia, cough, fever, and green sputum. Chest x-ray was
performed with left lower lobe infiltrate. The patient was admitted with bronchitis. Sputum
cultures were obtained in the ED as it was discovered the patient never filled the Z-Max
prescription. Sputum showed Staph and the patient was started on Vancomycin. The patient
was discharged with a diagnosis of acute bronchitis. The diagnosis query that could better
reflect the severity of illness and resources utilized for this patient and is clinically supported
would be
a.Acute or chronic bronchitis
b.Sepsis
c.Pneumonia
d.Sepsis and pneumonia
c Based on failed outpatient treatment the clinical findings of tachycardia, cough, fever, and
green-sputum, chest x-ray was performed with left lower lobe infiltrate, and positive sputum
cultures, query could be warranted for pneumonia.
•Is conflicting, imprecise, incomplete, illegible, ambiguous, or inconsistent
•Describes or is associated with clinical indicators without a definitive relationship to an
underlying diagnosis
•Includes clinical indicators, diagnostic evaluation, and/or treatment not related to a specific
condition or procedure
•Provides a diagnosis without underlying clinical validation
•Is unclear for present on admission indicator assignment
A patient was admitted with a CVA due to subarachnoid hemorrhage. On day two, it was
noted the patient had an elevated BUN and creatinine 3 times the baseline with anuria. The
physician documents acute kidney injury or failure. This diagnosis may warrant
a.Query for acute renal failure
b.Query for present on admission
c.No query warranted
d.Query for CVA
c No query warranted. There is no conflicting, unclear information.
•Is conflicting, imprecise, incomplete, illegible, ambiguous, or inconsistent
•Describes or is associated with clinical indicators without a definitive relationship to an
underlying diagnosis
•Includes clinical indicators, diagnostic evaluation, and/or treatment not related to a specific
condition or procedure
Page 3 of 35
, •Provides a diagnosis without underlying clinical validation
•Is unclear for present on admission indicator assignment
A new CDS performed her daily reviews and utilized a discharge summary performed by the
resident. During reconciliation of reviews, it was noted that the attending physician refused to
sign the discharge summary and dictated an addendum. The CDS received a note from the
department manager which stated _______ is responsible for the content of the record as the
primary physician
a.Attending physician
b.Head nurse
c.Consulting physician
d.Admitting nurse
a The physician principally responsible for the patient's hospital care generally dictates the
discharge summary. However, a resident, physician assistant, or nurse practitioner who is being
supervised by the attending physician may complete this task. Regardless of who documents it,
the attending physician is responsible for the content and quality of the summary and must date
and sign it (Shaw and Carter 2014; Fahrenholz and Russo 2013, 284).
The following conditions are considered _________: ABO incompatibility, falls and trauma, air
embolism, stage III and IV ulcers
a.PSIs (Patient safety indicators)
b.POAs (Present on admission indicators)
c.HACs (Hospital acquired conditions)
d.Acute and chronic conditions
c As part of the Inpatient Prospective Payment System (IPPS) Fiscal Year (FY) 2009 Final Rule,
CMS included 10 categories of conditions that were selected for as Hospital Acquired
Conditions. Currently there are 14 categories which include Air Embolism, Blood Incompatibility,
Stage III and IV Pressure Ulcers, and Falls and Trauma. See
https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/HospitalAcqCond/Hospital-
Acquired_Conditions.html for full listing (CMS 2013).
The CDI manager at Star Hospital has been concerned about the hospital quality ratings over
the past 2 years. She has been focused on educating physicians on documentation and
working with CDS staff on hospital acquired conditions, MCC/CC capture. She may also want
to educate regarding which area below to increase quality score:
a.The principal diagnosis
b.The principal procedure
Page 4 of 35
