CDIP EXAM 2026 COMPREHENSIVE HEALTH
INFORMATION MANAGEMENT AND
DOCUMENTATION IMPROVEMENT REVIEW
PACKAGE
◉ 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.
Answer: 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.
Answer: 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.
Answer: 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.
Answer: 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.
Answer: 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 32-year-old female had a liver transplant 2 years ago. She has
been experiencing problems with her kidneys with a GFR of 20 and
Stage IV CKD. She is noted to have some jaundice. Based on this:
a.Query should be performed for complication of liver transplant
b.Query should be performed for rejection of liver transplant
c.Query should not be performed as there are no liver complications
d.No additional documentation needed for reporting.
Answer: a It is noted that the patient has a previous liver transplant
and experiencing jaundice. If a transplant complication such as
failure or rejection or other transplant complication is documented,
see section I.C. 19.g for information on coding complications of a
kidney transplant. If the documentation is unclear as to whether the
patient has a complication of the transplant, query the provider
(ICD-10-CM Official Guidelines for Coding and Reporting 2016b, 52).
◉ When a patient is admitted for treatment of a secondary
malignancy with an active primary site the principal diagnosis
should be:
a.The primary malignancy
INFORMATION MANAGEMENT AND
DOCUMENTATION IMPROVEMENT REVIEW
PACKAGE
◉ 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.
Answer: 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.
Answer: 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.
Answer: 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.
Answer: 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.
Answer: 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 32-year-old female had a liver transplant 2 years ago. She has
been experiencing problems with her kidneys with a GFR of 20 and
Stage IV CKD. She is noted to have some jaundice. Based on this:
a.Query should be performed for complication of liver transplant
b.Query should be performed for rejection of liver transplant
c.Query should not be performed as there are no liver complications
d.No additional documentation needed for reporting.
Answer: a It is noted that the patient has a previous liver transplant
and experiencing jaundice. If a transplant complication such as
failure or rejection or other transplant complication is documented,
see section I.C. 19.g for information on coding complications of a
kidney transplant. If the documentation is unclear as to whether the
patient has a complication of the transplant, query the provider
(ICD-10-CM Official Guidelines for Coding and Reporting 2016b, 52).
◉ When a patient is admitted for treatment of a secondary
malignancy with an active primary site the principal diagnosis
should be:
a.The primary malignancy
