CDIP Domain 1: Clinical Coding Practice EXAM 2024/2025 |
ACTUAL EXAM WITH A STUDY GUIDE AND PRACTICE EXAM
| ACCURATE REAL EXAM QUESTIONS AND ANSWERS |
GUARANTEED PASS | LATEST UPDATE | GRADED A
Coding Clinic - ✔✔ANSW✔✔..Valuable reference tool for coders that is published by
AHA each quarter
CPT - ✔✔ANSW✔✔..Current Procedural Terminology
MS-DRGs - ✔✔ANSW✔✔..Medicare Severity-Diagnosis Related Groups
CPT Assistant - ✔✔ANSW✔✔..Monthly publication by the AMA that provides coding
advice for CPT coding scenarios
Encoder Nosology - ✔✔ANSW✔✔..Provides coding professionals from the encoder
company that are available to help answer tough coding questions
History & Physical - ✔✔ANSW✔✔..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 - ✔✔ANSW✔✔..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 - ✔✔ANSW✔✔..Summarize the invasive procedures
performed and any samples that are removed from the patient's body
Pathology report - ✔✔ANSW✔✔..Provides detailed information from the pathologist of
the facility as to the status of the tissues or organs removed from the patient's body
Encoder - ✔✔ANSW✔✔..Specialty software used to facilitate the assignment of
diagnostic and procedural codes according to the rules of the coding system
What is the value of utilizing coding software? - ✔✔ANSW✔✔..It facilitates accurate
coding by providing links to coding resources, groups diagnosis and procedure codes to
, the correct MS-DRG, and provides edits with additional information for the coder to
consider when placing codes into the encoder
Principal diagnosis - ✔✔ANSW✔✔..Diagnosis that, after study, is the reason for the
patient's admission to the hospital.
Secondary diagnoses - ✔✔ANSW✔✔..Additional supporting information for the
conditions the patient is being cared for
MCC - ✔✔ANSW✔✔..Major Complication or Comorbidity
CC - ✔✔ANSW✔✔..Complication or Comorbidity
CMI - ✔✔ANSW✔✔..Case Mix Index
LOS - ✔✔ANSW✔✔..Length of Stay
Complication - ✔✔ANSW✔✔..A condition arising during the hospital stay that prolongs
the LOS by at least one day in approximately 75% of the cases
Comorbidity - ✔✔ANSW✔✔..A pre-existing condition which because of its presence
with the principal diagnosis will increase the LOS by at least one day in 75% of the
cases
Primary procedures - ✔✔ANSW✔✔..Procedure codes that best represent the procedure
that has been performed
Secondary procedures - ✔✔ANSW✔✔..Do not typically impact the MS-DRG; however,
they are important for capturing the details of the care the patient has received while in
the hospital.
Coding conventions for ICD-10-CM - ✔✔ANSW✔✔..General rules for the use of the
classification independent of the guidelines
Letter that ICD-10 utilizes as a placeholder for certain codes - ✔✔ANSW✔✔..X
Excludes1 - ✔✔ANSW✔✔..Indicates that the code excluded should never be used with
the code above the Excludes1 note.
Excludes2 - ✔✔ANSW✔✔..Indicates that, when appropriate, it is acceptable to use both
the code and the excluded code together.
Inclusion terms - ✔✔ANSW✔✔..List of terms that are included under some codes. They
are the conditions for which the code should be used.
ACTUAL EXAM WITH A STUDY GUIDE AND PRACTICE EXAM
| ACCURATE REAL EXAM QUESTIONS AND ANSWERS |
GUARANTEED PASS | LATEST UPDATE | GRADED A
Coding Clinic - ✔✔ANSW✔✔..Valuable reference tool for coders that is published by
AHA each quarter
CPT - ✔✔ANSW✔✔..Current Procedural Terminology
MS-DRGs - ✔✔ANSW✔✔..Medicare Severity-Diagnosis Related Groups
CPT Assistant - ✔✔ANSW✔✔..Monthly publication by the AMA that provides coding
advice for CPT coding scenarios
Encoder Nosology - ✔✔ANSW✔✔..Provides coding professionals from the encoder
company that are available to help answer tough coding questions
History & Physical - ✔✔ANSW✔✔..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 - ✔✔ANSW✔✔..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 - ✔✔ANSW✔✔..Summarize the invasive procedures
performed and any samples that are removed from the patient's body
Pathology report - ✔✔ANSW✔✔..Provides detailed information from the pathologist of
the facility as to the status of the tissues or organs removed from the patient's body
Encoder - ✔✔ANSW✔✔..Specialty software used to facilitate the assignment of
diagnostic and procedural codes according to the rules of the coding system
What is the value of utilizing coding software? - ✔✔ANSW✔✔..It facilitates accurate
coding by providing links to coding resources, groups diagnosis and procedure codes to
, the correct MS-DRG, and provides edits with additional information for the coder to
consider when placing codes into the encoder
Principal diagnosis - ✔✔ANSW✔✔..Diagnosis that, after study, is the reason for the
patient's admission to the hospital.
Secondary diagnoses - ✔✔ANSW✔✔..Additional supporting information for the
conditions the patient is being cared for
MCC - ✔✔ANSW✔✔..Major Complication or Comorbidity
CC - ✔✔ANSW✔✔..Complication or Comorbidity
CMI - ✔✔ANSW✔✔..Case Mix Index
LOS - ✔✔ANSW✔✔..Length of Stay
Complication - ✔✔ANSW✔✔..A condition arising during the hospital stay that prolongs
the LOS by at least one day in approximately 75% of the cases
Comorbidity - ✔✔ANSW✔✔..A pre-existing condition which because of its presence
with the principal diagnosis will increase the LOS by at least one day in 75% of the
cases
Primary procedures - ✔✔ANSW✔✔..Procedure codes that best represent the procedure
that has been performed
Secondary procedures - ✔✔ANSW✔✔..Do not typically impact the MS-DRG; however,
they are important for capturing the details of the care the patient has received while in
the hospital.
Coding conventions for ICD-10-CM - ✔✔ANSW✔✔..General rules for the use of the
classification independent of the guidelines
Letter that ICD-10 utilizes as a placeholder for certain codes - ✔✔ANSW✔✔..X
Excludes1 - ✔✔ANSW✔✔..Indicates that the code excluded should never be used with
the code above the Excludes1 note.
Excludes2 - ✔✔ANSW✔✔..Indicates that, when appropriate, it is acceptable to use both
the code and the excluded code together.
Inclusion terms - ✔✔ANSW✔✔..List of terms that are included under some codes. They
are the conditions for which the code should be used.
