CDIP Practice Exam 2 WITH ANSWERS

CDIP Practice Exam 2 WITH ANSWERS |\ |\ |\ |\ |\




If the physician does not document the diagnosis, the
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coding professional cannot assume the patient has a
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diagnosis based solely on |\ |\ |\




a.An abnormal lab finding
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b.Abnormal pathology reports |\ |\




c.Both A and B |\ |\ |\




d.None of the above - CORRECT ANSWERS ✔✔c The coder
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cannot assume diagnoses on abnormal findings such as
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lab reports. Abnormal findings (laboratory, X-ray,
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pathologic, and other diagnostic results) are not coded |\ |\ |\ |\ |\ |\ |\ |\



and reported unless the physician indicates their clinical
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significance. If the findings are outside the normal range |\ |\ |\ |\ |\ |\ |\ |\ |\



and the physician has ordered other tests to evaluate the
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condition or prescribed treatment, it is appropriate to ask
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the physician whether the diagnosis should be added
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(AHA 1990, 15). |\ |\




These documents would be used for are used by clinicians
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and providers to identify abnormal temperature, blood
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pressure, pulse, respiration, oxygen levels, and other |\ |\ |\ |\ |\ |\ |\



indicators.
a.Nurses' graphic records |\ |\




b.Vital sign flowsheets |\ |\

,c.Both A and B |\ |\ |\




d.None of the above - CORRECT ANSWERS ✔✔c Clinicians
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and providers utilize various documents to identify
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abnormal temperature, blood pressure, pulse, respiration,
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oxygen levels, and other indicators. These documents are
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often called nurses' graphic records or vital sign
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flowsheets (Hess 2015, 43). |\ |\ |\




The American Hospital Association (AHA), the American
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Health Information Management Association (AHIMA),
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Center for Medicare and Medicaid Services (CMS), and
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National Center for Healthcare Statistics (NCHS) are all
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a.Cooperating parties |\




b.Governing bodies |\




c.Coding associations |\




d.Work independently to develop coding guidelines -
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CORRECT ANSWERS ✔✔a The American Hospital |\ |\ |\ |\ |\ |\



Association (AHA), the American Health Information |\ |\ |\ |\ |\ |\



Management Association (AHIMA), Center for Medicare |\ |\ |\ |\ |\ |\



and Medicaid Services (CMS), and National Center for
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Health Statistics (NCHS) are all cooperating parties that
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developed and approved ICD-10-CM/PCS (ICD-10-CM |\ |\ |\ |\ |\



Official Guidelines for Coding and Reporting 2016a, 1).
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A patient was admitted with HIV and pneumocystic carini.
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The patient should have a principal diagnosis in ICD-10
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of:

,a.AIDS
b.Asymptomatic HIV |\




c.Pneumonia
d.Not enough information - CORRECT ANSWERS ✔✔a If a
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patient is admitted for an HIV-related condition, the
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principal diagnosis should be B20, Human
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immunodeficiency virus [HIV] disease followed by |\ |\ |\ |\ |\ |\



additional diagnosis codes for all reported HIV-related
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conditions (ICD-10-CM Official Guidelines for Coding and
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Reporting 2016a, 17). |\ |\




APR-DRGs have levels (subclasses) of severity entitled:
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a.Excessive, Major, Moderate, Minor |\ |\ |\




b.Extreme, Major, Moderate, Minor |\ |\ |\




c.Extreme, Major, Moderate, Minimal |\ |\ |\




d.Excessive, Major - CORRECT ANSWERS ✔✔b The APR- |\ |\ |\ |\ |\ |\ |\



DRG system is distributed into levels (subclasses) similar
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to MS-DRGs. These levels are entitled Extreme, Major,
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Moderate, Minor (Hess 2015, 48) |\ |\ |\ |\




During an outpatient procedure for removal of a bladder
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cyst, the urologist accidentally tore the urethral sphincter
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requiring an observation stay. This should be assigned as
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the principal diagnosis:
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a.The reason for the outpatient surgery
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, b.The reason for admission
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c.Either the reason for the outpatient surgery or the
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reason for admission |\ |\




d.None of the above - CORRECT ANSWERS ✔✔a When a
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patient presents for outpatient surgery and develops
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complications requiring admission to observation, code |\ |\ |\ |\ |\ |\



the reason for the surgery as the first reported diagnosis
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(reason for the encounter), followed by codes for the
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complications as secondary diagnoses (ICD-10-CM Official |\ |\ |\ |\ |\



Guidelines for Coding and Reporting 2016a, 103).
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In 1990, 3M created which DRG system that several
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states use for Medicaid reimbursement and is also used
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by facilities to analyze some portion of the data for
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Medicare Quality Indicators. What is this system called?
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a.MS-DRGs
b.AP-DRGs
c.APR-DRGs
d.CPT-DRGs - CORRECT ANSWERS ✔✔c In 1990, 3M |\ |\ |\ |\ |\ |\ |\ |\



created APR-DRGs, which several states use for Medicaid
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reimbursement. APR-DRGs are used by facilities to |\ |\ |\ |\ |\ |\ |\



analyze some portion of the data for Medicare Quality
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Indicators (Hess 2015, 48) |\ |\ |\




A patient was admitted to an acute care facility with a
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temperature of 102 and atrial fibrillation. The chest x-ray |\ |\ |\ |\ |\ |\ |\ |\ |\