CDIP EXAM 2026 CERTIFICATION EVALUATION
CLINICAL DOCUMENTATION INTEGRITY
PRACTICE REVIEW AND STUDY GUIDE
◉ Assign the best answer to complete the following sentence. The
CPT codes for treatment of fractures:
a.Use the terminology "manipulation" rather than "reduction" of
fracture
b.Include internal fixation in all codes
c.Do not include application of cast
d.Do not differentiate between open and closed treatment; CPT only
specifies the site of the fracture.
Answer: a Manipulation refers to the attempted reduction or
restoration of a dislocated joint or fracture (Smith 2015, 84)
◉ In CPT, if a patient has two lacerations of the arm that are repaired
with simple closures, the coder would assign:
a.Two CPT codes expressing each laceration repair
b.One CPT code for the largest laceration
c.One CPT code, adding the lengths of the lacerations together
d.One CPT code for the most complex closure.
Answer: c When multiple wounds are repaired with the same
closure type (for example, simple), lengths of the wounds in the
,same classification and from all anatomical sites that are grouped
together into the same code descriptor should be added together
(Smith 2015, 67).
◉ Patient admitted for laparoscopic repair of right diaphragmatic
hernia. Assign the ICD-10-PCS procedure code for this surgery.
0BQR4ZZ Repair right diaphragm, percutaneous endoscopic
approach
0BQROZZ Repair right diaphragm, open approach
0BQS4ZZ Repair left diaphragm, percutaneous endoscopic approach
0BQSOZZ Repair left diaphragm, open approach
a.0BQR4ZZ
b.0BQR0ZZ
c.0BQS4ZZ
d.0BQS0ZZ.
Answer: a Surgery is the only treatment for diaphragmatic hernias.
ICD-10-PCS code 0BQR4ZZ, is used for laparoscopic repair of
diaphragmatic hernia (Garvin 2015, 192, 284)
◉ When trying to determine if documentation is present to
substantiate status asthmaticus, the coder should review the record
for what terms and phrases?
a.Intractable pneumonia
b.Refractory asthma and severe, intractable wheezing
,c.Airway obstruction relieved by bronchodilators
d.Limited but pronounced wheezing.
Answer: b Status asthmaticus is defined as continual wheezing in
spite of therapy (Leon-Chisen 2013, 230).
◉ Gastrointestinal bleeding can manifest as:
a.Hematemesis, which indicates acute upper gastrointestinal
hemorrhage
b.Petechia
c.Vomiting
d.Constipation, which indicates upper or lower gastrointestinal
hemorrhage.
Answer: a Gastrointestinal bleeding manifests itself in several ways.
These are hematemesis, melena, occult bleeding, hematochezia
(Leon-Chisen 2013, 244).
◉ Which types of pacemaker devices have a unique ICD-10-PCS
code.
a.Dual chamber rate responsive
b.Single chamber, single chamber rate responsive, and dual chamber
c.Multiple chamber
d.Multiple chamber rate responsive.
Answer: b The three types of pacemakers are single chamber, single
chamber rate responsive, and dual chamber. A single chamber uses a
, single lead; a dual chamber requires two leads, one in the atrium
and one in the ventricle. The leads should also be coded (Leon-
Chisen 2013, 416-418).
◉ Mechanical ventilation codes require consideration of which of
the following?
a.The time when a tracheal tube is inserted
b.The replacement of an endotracheal tube
c.The start time of endotracheal tube insertion followed by
mechanical ventilation
d.Mechanical ventilation during surgery.
Answer: c Codes for mechanical ventilation indicate whether the
patient was on mechanical ventilation for less than 24 hours, 24-96
consecutive hours and greater than 96 consecutive hours. The start
time for calculating the duration begins with the start time of
endotracheal tube insertion as the best method, followed by
mechanical ventilation or the time that a patient who is on
mechanical ventilation is admitted. The time ends with
discontinuance of mechanical ventilation (Leon-Chisen 2013, 239-
240).
◉ Abbreviations can be a source of patient safety issues due to
misinterpretation and miscommunication. Abbreviations in the
health record:
a.Are not permitted by Joint Commission standards
CLINICAL DOCUMENTATION INTEGRITY
PRACTICE REVIEW AND STUDY GUIDE
◉ Assign the best answer to complete the following sentence. The
CPT codes for treatment of fractures:
a.Use the terminology "manipulation" rather than "reduction" of
fracture
b.Include internal fixation in all codes
c.Do not include application of cast
d.Do not differentiate between open and closed treatment; CPT only
specifies the site of the fracture.
Answer: a Manipulation refers to the attempted reduction or
restoration of a dislocated joint or fracture (Smith 2015, 84)
◉ In CPT, if a patient has two lacerations of the arm that are repaired
with simple closures, the coder would assign:
a.Two CPT codes expressing each laceration repair
b.One CPT code for the largest laceration
c.One CPT code, adding the lengths of the lacerations together
d.One CPT code for the most complex closure.
Answer: c When multiple wounds are repaired with the same
closure type (for example, simple), lengths of the wounds in the
,same classification and from all anatomical sites that are grouped
together into the same code descriptor should be added together
(Smith 2015, 67).
◉ Patient admitted for laparoscopic repair of right diaphragmatic
hernia. Assign the ICD-10-PCS procedure code for this surgery.
0BQR4ZZ Repair right diaphragm, percutaneous endoscopic
approach
0BQROZZ Repair right diaphragm, open approach
0BQS4ZZ Repair left diaphragm, percutaneous endoscopic approach
0BQSOZZ Repair left diaphragm, open approach
a.0BQR4ZZ
b.0BQR0ZZ
c.0BQS4ZZ
d.0BQS0ZZ.
Answer: a Surgery is the only treatment for diaphragmatic hernias.
ICD-10-PCS code 0BQR4ZZ, is used for laparoscopic repair of
diaphragmatic hernia (Garvin 2015, 192, 284)
◉ When trying to determine if documentation is present to
substantiate status asthmaticus, the coder should review the record
for what terms and phrases?
a.Intractable pneumonia
b.Refractory asthma and severe, intractable wheezing
,c.Airway obstruction relieved by bronchodilators
d.Limited but pronounced wheezing.
Answer: b Status asthmaticus is defined as continual wheezing in
spite of therapy (Leon-Chisen 2013, 230).
◉ Gastrointestinal bleeding can manifest as:
a.Hematemesis, which indicates acute upper gastrointestinal
hemorrhage
b.Petechia
c.Vomiting
d.Constipation, which indicates upper or lower gastrointestinal
hemorrhage.
Answer: a Gastrointestinal bleeding manifests itself in several ways.
These are hematemesis, melena, occult bleeding, hematochezia
(Leon-Chisen 2013, 244).
◉ Which types of pacemaker devices have a unique ICD-10-PCS
code.
a.Dual chamber rate responsive
b.Single chamber, single chamber rate responsive, and dual chamber
c.Multiple chamber
d.Multiple chamber rate responsive.
Answer: b The three types of pacemakers are single chamber, single
chamber rate responsive, and dual chamber. A single chamber uses a
, single lead; a dual chamber requires two leads, one in the atrium
and one in the ventricle. The leads should also be coded (Leon-
Chisen 2013, 416-418).
◉ Mechanical ventilation codes require consideration of which of
the following?
a.The time when a tracheal tube is inserted
b.The replacement of an endotracheal tube
c.The start time of endotracheal tube insertion followed by
mechanical ventilation
d.Mechanical ventilation during surgery.
Answer: c Codes for mechanical ventilation indicate whether the
patient was on mechanical ventilation for less than 24 hours, 24-96
consecutive hours and greater than 96 consecutive hours. The start
time for calculating the duration begins with the start time of
endotracheal tube insertion as the best method, followed by
mechanical ventilation or the time that a patient who is on
mechanical ventilation is admitted. The time ends with
discontinuance of mechanical ventilation (Leon-Chisen 2013, 239-
240).
◉ Abbreviations can be a source of patient safety issues due to
misinterpretation and miscommunication. Abbreviations in the
health record:
a.Are not permitted by Joint Commission standards
