CCDS EXAM WITH 100 QUESTIOS AND ANSWERS
A. 1,2, and 3
1. Ensure that each medical record accurately reflects the patient's SOI and the resource consumption of
the admission
2. Provide physicians with necessary information so they can better understand coding guidelines
3. Assist in the accurate coding of diagnoses being monitored and treated - -The purpose of a concurrent
query is to:
1. Ensure that each medical record accurately reflects the patient's SOI and the resource consumption of
the admission
2. Provide physicians with necessary information so they can better understand coding guidelines
3. Assist in the accurate coding of diagnoses being monitored and treated
4. Eliminate retrospective queries
A. 1,2, and 3
B. 1,3, and 4
C. 2,3, and 4
D. 1,2,3, and 4
-A. 1,2, and 3
1. Use of accessory muscles
2. Work of breathing
3. Inability to speak more than a few words at a time - -Clinical indicators of acute respiratory failure most commonly include:
1. Use of accessory muscles
2. Work of breathing
3. Inability to speak more than a few words at a time
4. Oxygen saturations below 95% on 2L oxygen
5. Tachycardia
A. 1,2, and 3
B. 2,3, and 5
C. 3,4, and 5
D. 1,3, and 5
-A. Active bleeding does not need to be visualized in an endoscopy; the physician impression can be documented and coded - -When concurrently formulating a query to clarify whether a patient has a gastrointestinal hemorrhage, it is important to assist the physician in understanding which of the following coding rules?
A. Active bleeding does not need to be visualized in an endoscopy; the physician impression can be documented and coded
B. Bleeding must be visualized in order to code an active bleed C. A positive hemoccult is sufficient documentation to code GI hemorrhage
D. The EGD report will be used to code the location of the GI hemorrhage
-A. Assign acute renal failure as the principal diagnosis - -A patient with acute osteomyelitis is discharged
to home health with six weeks of additional IV therapy. Three weeks after discharge, the patient is admitted with "acute renal failure probably secondary to IV vancomycin administration." The CDI specialist should: A. Assign acute renal failure as the principal diagnosis
B. Query for appropriate dosing of the vancomycin since renal failure is a common side effect
C. Assign complication of the drug administration as the principal diagnosis
D. Assign osteomyelitis as the principal diagnosis since that was the patient's original problem and it had
not resolved at the time of admission
-A. Bleeding gastric ulcer - -A patient is admitted from the emergency department (ED) with a diagnosis of weakness and anemia. After admission and further treatment with packed red blood cells (PRBC), GI consult, and endoscopy, the physician includes the following diagnoses in the discharge summary: anemia, suspected bleeding gastric ulcer, and GERD. What would be the most appropriate principle diagnosis? A. Bleeding gastric ulcer B. Anemia C. GERD D. Weakness
-A. Bridging the gap between the coding and clinical perspectives - -Which of the following is a primary function of the CDI specialist? A. Bridging the gap between the coding and clinical perspectives
B. Supplying the provider with the specific wording needed to provide accurate code assignment
C. Explaining to coders the "true" meaning of the provider's documentation
D. Coding the record to the most appropriate DRG assignment
-A. Clinical indicators appropriate to the patient - -What must be present in a query to provide context as to why the query was initiated?
A. Clinical indicators appropriate to the patient
B. Patient identifiers
C. The choice of "unable to determine"
D. A listing of all the documents
-A. Colon cancer - -A patient is admitted with abdominal pain and the history and physical indicated a diagnosis of probable colon cancer. On day two, the physician documents acute renal failure in the progress notes and the patient receives IV fluids. The discharge summary lists possible metastatic colon cancer and acute renal failure. The principal diagnosis would be:
A. Colon cancer
B. Acute renal failure C. Abdominal pain
D. Metastatic neoplasm of the colon
-A. Data entry may not be accurate, causing a misrepresentation of MS-DRG shifts - -A CDI team has a query rate of 55%, but the CMI has had only marginal improvement. Which of the following may explain this situation?
A. Data entry may not be accurate, causing a misrepresentation of MS-DRG shifts
B. The physician response rate is high
C. The physician agreement rate is high
D. The CDI query rate is too high
-A. Dementia with a behavioral disorder provides a CC - -Why should providers link aggressive, combative, or violent behavior with dementia?
A. Dementia with a behavioral disorder provides a CC
B. There are quality indicators based on these combinations
C. This specification could map to a different DRG
D. It is important to capture violent behaviors for SOI
-A. Documentation indicates creatinine 2.4 on admission decreasing to 1.7 after 2 liters of fluid administered. Please clarify the condition you are monitoring and treating related to creatinine. Based upon presentation of altered mental status, are you also treating a CVA? - -A patient is admitted with weakness, dehydration, and AMS. The patient also has a history of CKD stage 2 with a baseline creatinine of 1.6, CHF, HTN, and CABG. Blood urea nitrogen (BUN) is 32, creatinine is 2.4, and urine analysis is positive for white blood cells. Head CT is negative for acute changes. The patient is started on IV fluids and antibiotics. Labs after 2 liters of fluid are BUN 28 and creatinine 1.7. The physician documents the following impression list:
-Dehydration with pre-renal azotemia
-UTI
-CKD
-AMS
Which of the following is an appropriate concurrent query?
A. Documentation indicates creatinine 2.4 on admission decreasing to 1.7 after 2 liters of fluid administered. Please clarify the condition you are monitoring and treating related to creatinine. Based upon presentation of altered mental status, are you also treating a CVA?
B. Please specify the reason for the IV fluids
C. Please specify the principal diagnosis
-A. Fluid overload - -A patient has documented ESRD and is placed in the ICU for "fluid overload". He receives dialysis daily and is a candidate for a kidney transplant. There is a match, and the patient is transferred to another hospital for the transplant. The principal diagnosis at the time of discharge from the first facility is: A. Fluid overload
A. 1,2, and 3
1. Ensure that each medical record accurately reflects the patient's SOI and the resource consumption of
the admission
2. Provide physicians with necessary information so they can better understand coding guidelines
3. Assist in the accurate coding of diagnoses being monitored and treated - -The purpose of a concurrent
query is to:
1. Ensure that each medical record accurately reflects the patient's SOI and the resource consumption of
the admission
2. Provide physicians with necessary information so they can better understand coding guidelines
3. Assist in the accurate coding of diagnoses being monitored and treated
4. Eliminate retrospective queries
A. 1,2, and 3
B. 1,3, and 4
C. 2,3, and 4
D. 1,2,3, and 4
-A. 1,2, and 3
1. Use of accessory muscles
2. Work of breathing
3. Inability to speak more than a few words at a time - -Clinical indicators of acute respiratory failure most commonly include:
1. Use of accessory muscles
2. Work of breathing
3. Inability to speak more than a few words at a time
4. Oxygen saturations below 95% on 2L oxygen
5. Tachycardia
A. 1,2, and 3
B. 2,3, and 5
C. 3,4, and 5
D. 1,3, and 5
-A. Active bleeding does not need to be visualized in an endoscopy; the physician impression can be documented and coded - -When concurrently formulating a query to clarify whether a patient has a gastrointestinal hemorrhage, it is important to assist the physician in understanding which of the following coding rules?
A. Active bleeding does not need to be visualized in an endoscopy; the physician impression can be documented and coded
B. Bleeding must be visualized in order to code an active bleed C. A positive hemoccult is sufficient documentation to code GI hemorrhage
D. The EGD report will be used to code the location of the GI hemorrhage
-A. Assign acute renal failure as the principal diagnosis - -A patient with acute osteomyelitis is discharged
to home health with six weeks of additional IV therapy. Three weeks after discharge, the patient is admitted with "acute renal failure probably secondary to IV vancomycin administration." The CDI specialist should: A. Assign acute renal failure as the principal diagnosis
B. Query for appropriate dosing of the vancomycin since renal failure is a common side effect
C. Assign complication of the drug administration as the principal diagnosis
D. Assign osteomyelitis as the principal diagnosis since that was the patient's original problem and it had
not resolved at the time of admission
-A. Bleeding gastric ulcer - -A patient is admitted from the emergency department (ED) with a diagnosis of weakness and anemia. After admission and further treatment with packed red blood cells (PRBC), GI consult, and endoscopy, the physician includes the following diagnoses in the discharge summary: anemia, suspected bleeding gastric ulcer, and GERD. What would be the most appropriate principle diagnosis? A. Bleeding gastric ulcer B. Anemia C. GERD D. Weakness
-A. Bridging the gap between the coding and clinical perspectives - -Which of the following is a primary function of the CDI specialist? A. Bridging the gap between the coding and clinical perspectives
B. Supplying the provider with the specific wording needed to provide accurate code assignment
C. Explaining to coders the "true" meaning of the provider's documentation
D. Coding the record to the most appropriate DRG assignment
-A. Clinical indicators appropriate to the patient - -What must be present in a query to provide context as to why the query was initiated?
A. Clinical indicators appropriate to the patient
B. Patient identifiers
C. The choice of "unable to determine"
D. A listing of all the documents
-A. Colon cancer - -A patient is admitted with abdominal pain and the history and physical indicated a diagnosis of probable colon cancer. On day two, the physician documents acute renal failure in the progress notes and the patient receives IV fluids. The discharge summary lists possible metastatic colon cancer and acute renal failure. The principal diagnosis would be:
A. Colon cancer
B. Acute renal failure C. Abdominal pain
D. Metastatic neoplasm of the colon
-A. Data entry may not be accurate, causing a misrepresentation of MS-DRG shifts - -A CDI team has a query rate of 55%, but the CMI has had only marginal improvement. Which of the following may explain this situation?
A. Data entry may not be accurate, causing a misrepresentation of MS-DRG shifts
B. The physician response rate is high
C. The physician agreement rate is high
D. The CDI query rate is too high
-A. Dementia with a behavioral disorder provides a CC - -Why should providers link aggressive, combative, or violent behavior with dementia?
A. Dementia with a behavioral disorder provides a CC
B. There are quality indicators based on these combinations
C. This specification could map to a different DRG
D. It is important to capture violent behaviors for SOI
-A. Documentation indicates creatinine 2.4 on admission decreasing to 1.7 after 2 liters of fluid administered. Please clarify the condition you are monitoring and treating related to creatinine. Based upon presentation of altered mental status, are you also treating a CVA? - -A patient is admitted with weakness, dehydration, and AMS. The patient also has a history of CKD stage 2 with a baseline creatinine of 1.6, CHF, HTN, and CABG. Blood urea nitrogen (BUN) is 32, creatinine is 2.4, and urine analysis is positive for white blood cells. Head CT is negative for acute changes. The patient is started on IV fluids and antibiotics. Labs after 2 liters of fluid are BUN 28 and creatinine 1.7. The physician documents the following impression list:
-Dehydration with pre-renal azotemia
-UTI
-CKD
-AMS
Which of the following is an appropriate concurrent query?
A. Documentation indicates creatinine 2.4 on admission decreasing to 1.7 after 2 liters of fluid administered. Please clarify the condition you are monitoring and treating related to creatinine. Based upon presentation of altered mental status, are you also treating a CVA?
B. Please specify the reason for the IV fluids
C. Please specify the principal diagnosis
-A. Fluid overload - -A patient has documented ESRD and is placed in the ICU for "fluid overload". He receives dialysis daily and is a candidate for a kidney transplant. There is a match, and the patient is transferred to another hospital for the transplant. The principal diagnosis at the time of discharge from the first facility is: A. Fluid overload
