CDIP Practice Exam 2 Marking Scheme

CDIP Practice Exam 2 Marking Scheme A physician admits a patient with shortness of breath and chest pain, then treats the patient with Lasix, oxygen, and Theophylline. The physician's final documented diagnosis for the patient is acute exacerbation of COPD. What is missing from this diagnosis that would make it reliable information in the treatment of this patient? a.No additional information is needed. b.The type of COPD c.The reason the patient was treated with Lasix d.The reason for the Theophylline - ANSWER If the physician does not document the diagnosis, the coding professional cannot assume the patient has a diagnosis based solely on a.An abnormal lab finding b.Abnormal pathology reports c.Both A and B d.None of the above - ANSWER c The coder cannot assume diagnoses on abnormal findings such as lab reports. Abnormal findings (laboratory, X-ray, pathologic, and other diagnostic results) are not coded and reported unless the physician indicates their clinical significance. If the findings are outside the normal range and the physician has ordered other tests to evaluate the condition or prescribed treatment, it is appropriate to ask the physician whether the diagnosis should be added (AHA 1990, 15). These documents would be used for are used by clinicians and providers to identify abnormal temperature, blood 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 - ANSWER c Clinicians and providers utilize various documents to identify abnormal temperature, blood pressure, pulse, respiration, oxygen levels, and other indicators. These documents are often called nurses' graphic records or vital sign flowsheets (Hess 2015, 43). The American Hospital Association (AHA), the American Health Information Management Association (AHIMA), Center for Medicare and Medicaid Services (CMS), and National Center for Healthcare Statistics (NCHS) are all a.Cooperating parties b.Governing bodies c.Coding associations d.Work independently to develop coding guidelines - ANSWER a The American Hospital Association (AHA), the American Health Information Management Association (AHIMA), Center for Medicare and Medicaid Services (CMS), and National Center for Health Statistics (NCHS) are all cooperating parties that developed and approved ICD-10-CM/PCS (ICD-10-CM Official Guidelines for Coding and Reporting 2016a, 1). A patient was admitted with HIV and pneumocystic carini. The patient should have a principal diagnosis in ICD-10 of: a.AIDS b.Asymptomatic HIV c.Pneumonia d.Not enough information - ANSWER a If a patient is admitted for an HIV-related condition, the principal diagnosis should be B20, Human immunodeficiency virus [HIV] disease followed by additional diagnosis codes for all reported HIV-related conditions (ICD-10-CM Official Guidelines for Coding and Reporting 2016a, 17).