CDIP Domain 1: Clinical Coding Practice Exam 2023

Coding Clinic - Answer- Valuable reference tool for coders that is published by AHA each quarter CPT - Answer- Current Procedural Terminology MS-DRGs - Answer- Medicare Severity-Diagnosis Related Groups CPT Assistant - Answer- Monthly publication by the AMA that provides coding advice for CPT coding scenarios Encoder Nosology - Answer- Provides coding professionals from the encoder company that are available to help answer tough coding questions History & Physical - Answer- Provides the initial chief complaint and initial impressions of the provider when the patient is first admitted. It also has a comprehensive physical review of the patient's body systems and vital signs, and provides the initial treatment plan, medications, and tests that are being ordered to treat the patient. Progress Notes - Answer- Provide information about what is going on with the patient on a day-to-day basis; they should include the diagnoses that are being treated as well as any information about any changes in the patient's well-being and tests/procedures being performed. Operative and Pathology Reports - Answer- Summarize the invasive procedures performed and any samples that are removed from the patient's body Pathology report - Answer- Provides detailed information from the pathologist of the facility as to the status of the tissues or organs removed from the patient's body