CDIP Practice Exam 2
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
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
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
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
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
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).
APR-DRGs have levels (subclasses) of severity entitled:
a.Excessive, Major, Moderate, Minor
b.Extreme, Major, Moderate, Minor
c.Extreme, Major, Moderate, Minimal
,d.Excessive, Major
b The APR-DRG system is distributed into levels (subclasses) similar to
MS-DRGs. These levels are entitled Extreme, Major, Moderate, Minor
(Hess 2015, 48)
During an outpatient procedure for removal of a bladder cyst, the
urologist accidentally tore the urethral sphincter requiring an observation
stay. This should be assigned as the principal diagnosis:
a.The reason for the outpatient surgery
b.The reason for admission
c.Either the reason for the outpatient surgery or the reason for admission
d.None of the above
a 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 2016a, 103).
In 1990, 3M created which DRG system that several states use for
Medicaid reimbursement and is also used by facilities to analyze some
portion of the data for Medicare Quality Indicators. What is this system
called?
a.MS-DRGs
b.AP-DRGs
c.APR-DRGs
d.CPT-DRGs
c In 1990, 3M created APR-DRGs, which several states use for Medicaid
reimbursement. APR-DRGs are used by facilities to analyze some
portion of the data for Medicare Quality Indicators (Hess 2015, 48)
A patient was admitted to an acute care facility with a temperature of 102
and atrial fibrillation. The chest x-ray reveals pneumonia with
subsequent documentation by the physician of pneumonia in the
progress notes and discharge summary. The patient was treated with
, oral antiarrhythmia medications and IV antibiotics. What is the principal
diagnosis?
a.Pneumonia
b.Arrhythmia
c.Atrial fibrillation
d.Both a and c
a The patient presented with clinical signs of Pneumonia along with
treatment. The atrial fibrillation was a chronic condition that can be
reported additionally (CMS 2016b).
The Cooperating Parties, which develop and approve ICD-10, include:
a.American Hospital Association (AHA) and American Health Information
Management Association (AHIMA)
b.American Hospital Association (AHA), American Health Information
Management Association (AHIMA), and Centers for Disease Control
(CDC)
c.American Hospital Association (AHA), American Health Information
Management Association (AHIMA), and Centers for Medicare and
Medicaid Services (CMS), and National Center for Health Statistics
(NCHS)
d.American Hospital Association (AHA), American Health Information
Management Association (AHIMA), and the World Health Organization
(WHO)
c The cooperating parties developed and approved ICD-10-CM/PCS and
include (4) organizations American Hospital Association (AHA),
American Health Information Management Association (AHIMA), and
Centers for Medicare and Medicaid Services (CMS), and National
Center for Health Statistics (NCHS) (CMS 2016c).
Mildred Smith was admitted to a nursing facility with the following
information: "Patient is being admitted for Organic Brain Syndrome."
Underneath the diagnosis, her medical information was listed along with
a summary of the care already provided. This information is documented
on the:
a.Transfer record
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
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
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
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
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
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).
APR-DRGs have levels (subclasses) of severity entitled:
a.Excessive, Major, Moderate, Minor
b.Extreme, Major, Moderate, Minor
c.Extreme, Major, Moderate, Minimal
,d.Excessive, Major
b The APR-DRG system is distributed into levels (subclasses) similar to
MS-DRGs. These levels are entitled Extreme, Major, Moderate, Minor
(Hess 2015, 48)
During an outpatient procedure for removal of a bladder cyst, the
urologist accidentally tore the urethral sphincter requiring an observation
stay. This should be assigned as the principal diagnosis:
a.The reason for the outpatient surgery
b.The reason for admission
c.Either the reason for the outpatient surgery or the reason for admission
d.None of the above
a 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 2016a, 103).
In 1990, 3M created which DRG system that several states use for
Medicaid reimbursement and is also used by facilities to analyze some
portion of the data for Medicare Quality Indicators. What is this system
called?
a.MS-DRGs
b.AP-DRGs
c.APR-DRGs
d.CPT-DRGs
c In 1990, 3M created APR-DRGs, which several states use for Medicaid
reimbursement. APR-DRGs are used by facilities to analyze some
portion of the data for Medicare Quality Indicators (Hess 2015, 48)
A patient was admitted to an acute care facility with a temperature of 102
and atrial fibrillation. The chest x-ray reveals pneumonia with
subsequent documentation by the physician of pneumonia in the
progress notes and discharge summary. The patient was treated with
, oral antiarrhythmia medications and IV antibiotics. What is the principal
diagnosis?
a.Pneumonia
b.Arrhythmia
c.Atrial fibrillation
d.Both a and c
a The patient presented with clinical signs of Pneumonia along with
treatment. The atrial fibrillation was a chronic condition that can be
reported additionally (CMS 2016b).
The Cooperating Parties, which develop and approve ICD-10, include:
a.American Hospital Association (AHA) and American Health Information
Management Association (AHIMA)
b.American Hospital Association (AHA), American Health Information
Management Association (AHIMA), and Centers for Disease Control
(CDC)
c.American Hospital Association (AHA), American Health Information
Management Association (AHIMA), and Centers for Medicare and
Medicaid Services (CMS), and National Center for Health Statistics
(NCHS)
d.American Hospital Association (AHA), American Health Information
Management Association (AHIMA), and the World Health Organization
(WHO)
c The cooperating parties developed and approved ICD-10-CM/PCS and
include (4) organizations American Hospital Association (AHA),
American Health Information Management Association (AHIMA), and
Centers for Medicare and Medicaid Services (CMS), and National
Center for Health Statistics (NCHS) (CMS 2016c).
Mildred Smith was admitted to a nursing facility with the following
information: "Patient is being admitted for Organic Brain Syndrome."
Underneath the diagnosis, her medical information was listed along with
a summary of the care already provided. This information is documented
on the:
a.Transfer record
