Clinical Documentation Toolkit Revision Guide Questions And Comprehensive

Clinical Documentation Toolkit
Revision Guide for Last-Minute Exam
Prep

In what year did ICD-10-CM/PCS go into effect in the United States




A. 2013




B. 2014




C. 2015




D. 2016 - Correct Answer ✔️✔️C. 2015


Which of the following is an inpatient classification scheme that categorizes

patients who share similar clinical characteristics?

,A. DRG




B. SOI




C. ROM




D. FAQ - Correct Answer ✔️✔️A. DRG


What is the most important factor in DRG assignment




A. Relative weight




B. Payment




C. Principal Diagnosis

,D. Secondary Diagnosis - Correct Answer ✔️✔️C. Principal Diagnosis


A patient is admitted for chronic diastolic congestive heart failure and

pneumonia. the patient is placed on IV Lasix and IV antibiotics on admission.

Which coding rule applies?




A. Two or more diagnosis that equally meets the criteria for principal diagnosis;

either may be sequenced first.




B. Two or more diagnosis that equally meets the criteria for principal diagnosis;

code the sign or symptom first




C. Two or more diagnosis that equally meets the criteria for principal diagnosis;

always choose the higher-paying DRG first




D. Two or more diagnosis that equally meets the criteria for principal diagnosis;

code the diagnosis as "probable." - Correct Answer ✔️✔️A. Two or more

, diagnosis that equally meets the criteria for principal diagnosis; either may be

sequenced first.


A physician documents "Right Lower lobe pneumonia due to aspiration." What Is

the principal diagnosis?




A. RLL pneumonia




B. Aspiration pneumonia




C. Infectious pneumonia




D. Simple pneumonia - Correct Answer ✔️✔️B. Aspiration pneumonia


Discharge summary states "chest pain due to gastroesophageal reflux versus

esophageal spasm." What is the correct principal diagnosis?