CDIP CORE REVIEWS QUESTIONS AND ANSWERS SET
A+
✔✔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 - ✔✔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 - ✔✔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 - ✔✔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 - ✔✔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 - ✔✔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 - ✔✔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 - ✔✔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
released. It was discussed with the patient to take her hydrocodone as prescribed and
continue her medications for osteoporosis, hypertension, and calcium. This fracture:
a.is only a minor setback for the patient
b.has Core measures to meet for quality
c.is coded as pathologic with osteoporosis
,d.is coded as a traumatic fracture - ✔✔c Osteoporosis with current pathological fracture:
A code from category M80, not a traumatic fracture code, should be used for any patient
with known osteoporosis who suffers a fracture, even if the patient had a minor fall or
trauma, if that fall or trauma would not usually break a normal, healthy bone (ICD-10-
CM Official Guidelines for Coding and Reporting 2016b, 51).
✔✔A patient presented with pain in the right foot; right big toe. On physical exam, the
toe was noted to be red and warm to touch. Laboratory findings show an elevated uric
acid. The patient has a previous medication history of colchicine. Which diagnosis
below was most likely listed in the diagnostic statement?
a.Arthritis of the right toe
b.Gout of the right toe
c.Cellulitis of the right toe
d.Elevated uric acid - ✔✔b Gout inflammation of the joints. This is a metabolic disorder
that in acute cases can cause some joints swell up become very painful. Crystals of uric
acid that build up mostly in the joints cause the inflammation (NIH n.d.)
✔✔This 75-year-old patient has a history of Alzheimer's disease. She is admitted with
hypertensive encephalopathy with increased confusion. Her daughter states that she
has noticed that she filled her once a day antihypertensive prescription 14 days ago and
it still contains the original 30 tablets. This patient most likely could be queried for:
a.Overdosing
b.Underdosing
c.A drug interaction
d.Advancing Alzheimer's - ✔✔b Using a prescribed medication less frequently than
prescribed, in small doses, or not using the medication as instructed should be
documented as "underdosing" by the provider (AHIMA 2015, 56)
✔✔A patient was admitted with elevated white blood cells at 15.7 in the presence of
cough and shortness of breath. Patient with a history of CHF on Lasix and COPD
exhibiting symptoms of exacerbation with pulmonary edema along with crackles in the
bases on exam with underlying infectious process, pneumonia. Chest x-ray shows left
basilar infiltrate. The patient was started on antibiotic; azithromycin with Rocephin
added. Physician lists CHF, pneumonia, COPD. In this example, pneumonia is the:
a.Principal diagnosis
b.Secondary diagnosis
c.Query warranted
d.Not enough information for assignment of a principal - ✔✔a The principal diagnosis is
defined in the Uniform Hospital Discharge Data Set (UHDDS) as "that condition
established after study to be chiefly responsible for occasioning the admission of the
patient to the hospital for care." In this example, pneumonia is the principal based on
presenting signs, symptoms, workup, and treatment (ICD-10-CM Official Guidelines for
Coding and Reporting 2016b, 97)
✔✔Based on the example above, the other/secondary diagnosis(es) would be:
, a.CHF, pneumonia
b.Pneumonia, COPD
c.CHF, COPD
d.COPD - ✔✔c The CHF and COPD meet the definition for "other diagnoses" as
additional conditions that affect patient care in terms of requiring: clinical evaluation; or
therapeutic treatment; or diagnostic procedures; or extended length of hospital stay; or
increased nursing care and/or monitoring (ICD-10-CM Official Guidelines for Coding
and Reporting 2016b, 100).
✔✔Following a cholecystectomy for gallstones, a patient developed intractable nausea
and vomiting requiring an observation stay. The principal diagnosis for this observation
stay should be:
a.Gallstones
b.Nausea and Vomiting
c.Intractable nausea and vomiting
d.Postop nausea and vomiting - ✔✔a Per Official Coding Guidelines, when a patient is
admitted for observation for a medical condition, assign a code for the medical condition
as the first-listed diagnosis. When a patient presents for outpatient surgery and
develops complications requiring admission to observation, code the reason for the
surgery as the first reported diagnosis (reason for the encounter), followed by codes for
the complications as secondary diagnoses (ICD-10-CM Official Guidelines for Coding
and Reporting 2016b, 103).
✔✔The CDS performs case review after admission to obtain the:
a.Case Mix Index
b.Core Measure Score
c.working DRG
d.final DRG - ✔✔c The CDS performs case review after admission to obtain the
"working DRG." Goal should be facility specific but usually 24-48 hours after admission
(Hess 2015, 376).
✔✔A patient is being seen in the clinic for possible CHF. She has pedal edema and
shortness of breath. The physician's office note states rule out, CHF; shortness of
breath. The patient's reported diagnosis for this outpatient visit should be:
a.CHF
b.Rule out CHF
c.Shortness of breath
d.Shortness of breath and pedal edema - ✔✔d The shortness of breath and pedal
edema would be reported for this outpatient visit. Do not code diagnoses documented
as "probable," "suspected," "questionable," "rule out," or "working diagnosis" or other
similar terms indicating uncertainty. Rather, code the condition(s) to the highest degree
of certainty for that encounter/visit, such as symptoms, signs, abnormal test results, or
other reason for the visit (ICD-10-CM Official Guidelines for Coding and Reporting
2016b, 104).
A+
✔✔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 - ✔✔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 - ✔✔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 - ✔✔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 - ✔✔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 - ✔✔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 - ✔✔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 - ✔✔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
released. It was discussed with the patient to take her hydrocodone as prescribed and
continue her medications for osteoporosis, hypertension, and calcium. This fracture:
a.is only a minor setback for the patient
b.has Core measures to meet for quality
c.is coded as pathologic with osteoporosis
,d.is coded as a traumatic fracture - ✔✔c Osteoporosis with current pathological fracture:
A code from category M80, not a traumatic fracture code, should be used for any patient
with known osteoporosis who suffers a fracture, even if the patient had a minor fall or
trauma, if that fall or trauma would not usually break a normal, healthy bone (ICD-10-
CM Official Guidelines for Coding and Reporting 2016b, 51).
✔✔A patient presented with pain in the right foot; right big toe. On physical exam, the
toe was noted to be red and warm to touch. Laboratory findings show an elevated uric
acid. The patient has a previous medication history of colchicine. Which diagnosis
below was most likely listed in the diagnostic statement?
a.Arthritis of the right toe
b.Gout of the right toe
c.Cellulitis of the right toe
d.Elevated uric acid - ✔✔b Gout inflammation of the joints. This is a metabolic disorder
that in acute cases can cause some joints swell up become very painful. Crystals of uric
acid that build up mostly in the joints cause the inflammation (NIH n.d.)
✔✔This 75-year-old patient has a history of Alzheimer's disease. She is admitted with
hypertensive encephalopathy with increased confusion. Her daughter states that she
has noticed that she filled her once a day antihypertensive prescription 14 days ago and
it still contains the original 30 tablets. This patient most likely could be queried for:
a.Overdosing
b.Underdosing
c.A drug interaction
d.Advancing Alzheimer's - ✔✔b Using a prescribed medication less frequently than
prescribed, in small doses, or not using the medication as instructed should be
documented as "underdosing" by the provider (AHIMA 2015, 56)
✔✔A patient was admitted with elevated white blood cells at 15.7 in the presence of
cough and shortness of breath. Patient with a history of CHF on Lasix and COPD
exhibiting symptoms of exacerbation with pulmonary edema along with crackles in the
bases on exam with underlying infectious process, pneumonia. Chest x-ray shows left
basilar infiltrate. The patient was started on antibiotic; azithromycin with Rocephin
added. Physician lists CHF, pneumonia, COPD. In this example, pneumonia is the:
a.Principal diagnosis
b.Secondary diagnosis
c.Query warranted
d.Not enough information for assignment of a principal - ✔✔a The principal diagnosis is
defined in the Uniform Hospital Discharge Data Set (UHDDS) as "that condition
established after study to be chiefly responsible for occasioning the admission of the
patient to the hospital for care." In this example, pneumonia is the principal based on
presenting signs, symptoms, workup, and treatment (ICD-10-CM Official Guidelines for
Coding and Reporting 2016b, 97)
✔✔Based on the example above, the other/secondary diagnosis(es) would be:
, a.CHF, pneumonia
b.Pneumonia, COPD
c.CHF, COPD
d.COPD - ✔✔c The CHF and COPD meet the definition for "other diagnoses" as
additional conditions that affect patient care in terms of requiring: clinical evaluation; or
therapeutic treatment; or diagnostic procedures; or extended length of hospital stay; or
increased nursing care and/or monitoring (ICD-10-CM Official Guidelines for Coding
and Reporting 2016b, 100).
✔✔Following a cholecystectomy for gallstones, a patient developed intractable nausea
and vomiting requiring an observation stay. The principal diagnosis for this observation
stay should be:
a.Gallstones
b.Nausea and Vomiting
c.Intractable nausea and vomiting
d.Postop nausea and vomiting - ✔✔a Per Official Coding Guidelines, when a patient is
admitted for observation for a medical condition, assign a code for the medical condition
as the first-listed diagnosis. When a patient presents for outpatient surgery and
develops complications requiring admission to observation, code the reason for the
surgery as the first reported diagnosis (reason for the encounter), followed by codes for
the complications as secondary diagnoses (ICD-10-CM Official Guidelines for Coding
and Reporting 2016b, 103).
✔✔The CDS performs case review after admission to obtain the:
a.Case Mix Index
b.Core Measure Score
c.working DRG
d.final DRG - ✔✔c The CDS performs case review after admission to obtain the
"working DRG." Goal should be facility specific but usually 24-48 hours after admission
(Hess 2015, 376).
✔✔A patient is being seen in the clinic for possible CHF. She has pedal edema and
shortness of breath. The physician's office note states rule out, CHF; shortness of
breath. The patient's reported diagnosis for this outpatient visit should be:
a.CHF
b.Rule out CHF
c.Shortness of breath
d.Shortness of breath and pedal edema - ✔✔d The shortness of breath and pedal
edema would be reported for this outpatient visit. Do not code diagnoses documented
as "probable," "suspected," "questionable," "rule out," or "working diagnosis" or other
similar terms indicating uncertainty. Rather, code the condition(s) to the highest degree
of certainty for that encounter/visit, such as symptoms, signs, abnormal test results, or
other reason for the visit (ICD-10-CM Official Guidelines for Coding and Reporting
2016b, 104).
