1
CDIP EXAM (CERTIFIED DOCUMENTATION
INTEGRITY PRACTITIONER) LATEST COMPLETE
QUESTIONS AND ANSWERS ALREADY GRADED A+
A 54-year-old female has been seen in outpatient surgery for a laparoscopic
appendectomy. The patient has hypertension, diabetes mellitus type II, on
insulin, appendicitis, and had a cholecystitis with cholecystectomy in 2015:
removed. All diagnosis except _________ would be coded:
a. Hypertension
b. Diabetes mellitus Type II
c. Cholecystitis
d. Appendicitis - (answer)c. Cholecystitis
The cholecystitis with cholecystitis should not be coded as an active condition;
it is a history of the condition. Do not code condition that were previously
treated and no longer exist. However, history codes (categories Z80-Z87) may
be used as secondary codes if the historical condition or family history has an
impact on current care or influence treatment.
A 63-year-old male presents to outpatient surgery for prostatectomy with
benign prostatic hypertrophy. After arriving in the OR and prior to induction of
anesthesia, the patient began to experience substernal chest pain. The patient
takes Lasix for long-standing history of congestive heart failure. The prostate
surgery is cancelled, and the patient was observed for 10 hours and discharged.
The patients first listed diagnosis should be:
a. Benign prostatic hypertrophy
b. Congestive heart failure
c. Canceled surgery
d. Chest pain - (answer)a. Benign prostatic hypertrophy
, 2
Benign prostatic hypertrophy should be the first listed. 1. Outpatient surgery:
When a patient presents for outgoing surgery (same-day surgery), code the
reason for the surgery as the first-listed diagnosis (reason for the encounter),
even if the surgery is not performed due to a contraindication. 2. Observation
stay: When a patient is admitted for observation for a medical condition, assign
a code for the medical condition as the first-listed diagnosis. 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 encounter), followed by codes for the complications as
secondary diagnoses.
A 50-year-old patient has a diagnosis of hypertension, on Amlodipine and
Humalog for Type II diabetes and was seen on follow-up. The provider adjusted
the dosage of Amlodipine and performed an A1C for glucose control. Audits
was performed, and the auditor stated these diagnoses should not be coded.
a. This is correct; only acute conditions should be coded.
b. This is incorrect; chronic conditions can be reported if treated.
c. The physician must document the reason for this visit.
d. Only the hypertension can be coded, as it was adjusted. - (answer)b. This is
incorrect; chronic conditions can be reported if treated.
Because the hypertension and diabetes are chronic; they may be coded and
reported as many times as the patient receives treatment and care for the
condition(s).
A patient is admitted for pneumonia and acute renal failure. The patient is
placed on IV antibiotics with diuresis on admission. The principal diagnosis
would be:
a. Pneumonia because the patient was given IV drug therapy.
b. Acute renal failure because the condition is stated as acute.
c. The pneumonia or the acute renal failure could be the principal diagnosis.
, 3
d. Neither, because the physician did not state which one was principal. -
(answer)c. The pneumonia or the acute renal failure could be the principal
diagnosis.
The pneumonia or the acute renal failure could be assigned as principal. Two or
more diagnoses that equally meet the definition of principal diagnosis in the
usual instance when two mor more diagnoses equally meet the criteria for
principal diagnosis as determined by the circumstances of admission,
diagnostic workup, and/or therapy provided, and the Alphabetic Index, Tabular
List, or another coding guidelines does not provide sequencing direction, any
one of the diagnoses may be sequenced first.
When physician documentation state Sp02 room air <91%, ABG p02 on room
air less then 60 mm, and proceeds with intubation an/or initiations of BiPAP,
the diagnosis is most likely:
a. Respiratory failure
b. Acute respiratory failure
c. Chronic respiratory failure
d. Acute or chronic respiratory failure - (answer)b. Acute respiratory failure
The respiratory failure can be determined by a partial pressure of oxygen
(Pa02) <60 mmHg with a normal or decreased partial pressure of carbon
dioxide (PaC02). Treatment of respiratory oxygenation and ventilation, as
needed.
Documentation review shows testing of cardiac troponin, echocardiography
with a plan for percutaneous coronary intervention (PCI). The patient is most
likely to be evaluated for:
a. Acute myocardial infarction
b. Chest pain
c. Gastroesophageal reflux disease (GERD)
, 4
d. Cerebrovascular accident (CVA) - (answer)a. Acute myocardial infarction
MI is characterized by presenting with chest discomfort or pressure that can
radiate to the neck, jaw, shoulder, or arm. It can be associated with ECG
changes and elevated biochemical markers; cardiac troponins.
During chart review, it is documented that the patient has sepsis. The CDI
professional should review the labs for testing to identify increased levels of a
substance made by muscle tissue and by red blood cells, which carry oxygen
from the lungs to other parts of the body and can lead to a type of acidosis.
This test is called a:
a. Complete blood count (CBC)
b. Chem 8
c. Kidney function test
d. Lactic acid - (answer)d. Lactic acid
A lactic acid test is utilized in the diagnosis of sepsis.
On CID review, it was noted that the patient stumbled on the sidewalk, and
workup reveals a small pelvic fracture at the symphysis. The MD states she
received Reclast annually. The CDI professional should query for what diagnosis
to reflect complexity and severity?
a. Fracture
b. Osteoporotic fracture
c. Cause of fracture
d. Traumatic fracture - (answer)b. Osteoporotic fracture
A code from category M80, not a traumatic fracture code, should be used for
any patient with known osteoporosis who suffers a fracture, even if the patient
CDIP EXAM (CERTIFIED DOCUMENTATION
INTEGRITY PRACTITIONER) LATEST COMPLETE
QUESTIONS AND ANSWERS ALREADY GRADED A+
A 54-year-old female has been seen in outpatient surgery for a laparoscopic
appendectomy. The patient has hypertension, diabetes mellitus type II, on
insulin, appendicitis, and had a cholecystitis with cholecystectomy in 2015:
removed. All diagnosis except _________ would be coded:
a. Hypertension
b. Diabetes mellitus Type II
c. Cholecystitis
d. Appendicitis - (answer)c. Cholecystitis
The cholecystitis with cholecystitis should not be coded as an active condition;
it is a history of the condition. Do not code condition that were previously
treated and no longer exist. However, history codes (categories Z80-Z87) may
be used as secondary codes if the historical condition or family history has an
impact on current care or influence treatment.
A 63-year-old male presents to outpatient surgery for prostatectomy with
benign prostatic hypertrophy. After arriving in the OR and prior to induction of
anesthesia, the patient began to experience substernal chest pain. The patient
takes Lasix for long-standing history of congestive heart failure. The prostate
surgery is cancelled, and the patient was observed for 10 hours and discharged.
The patients first listed diagnosis should be:
a. Benign prostatic hypertrophy
b. Congestive heart failure
c. Canceled surgery
d. Chest pain - (answer)a. Benign prostatic hypertrophy
, 2
Benign prostatic hypertrophy should be the first listed. 1. Outpatient surgery:
When a patient presents for outgoing surgery (same-day surgery), code the
reason for the surgery as the first-listed diagnosis (reason for the encounter),
even if the surgery is not performed due to a contraindication. 2. Observation
stay: When a patient is admitted for observation for a medical condition, assign
a code for the medical condition as the first-listed diagnosis. 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 encounter), followed by codes for the complications as
secondary diagnoses.
A 50-year-old patient has a diagnosis of hypertension, on Amlodipine and
Humalog for Type II diabetes and was seen on follow-up. The provider adjusted
the dosage of Amlodipine and performed an A1C for glucose control. Audits
was performed, and the auditor stated these diagnoses should not be coded.
a. This is correct; only acute conditions should be coded.
b. This is incorrect; chronic conditions can be reported if treated.
c. The physician must document the reason for this visit.
d. Only the hypertension can be coded, as it was adjusted. - (answer)b. This is
incorrect; chronic conditions can be reported if treated.
Because the hypertension and diabetes are chronic; they may be coded and
reported as many times as the patient receives treatment and care for the
condition(s).
A patient is admitted for pneumonia and acute renal failure. The patient is
placed on IV antibiotics with diuresis on admission. The principal diagnosis
would be:
a. Pneumonia because the patient was given IV drug therapy.
b. Acute renal failure because the condition is stated as acute.
c. The pneumonia or the acute renal failure could be the principal diagnosis.
, 3
d. Neither, because the physician did not state which one was principal. -
(answer)c. The pneumonia or the acute renal failure could be the principal
diagnosis.
The pneumonia or the acute renal failure could be assigned as principal. Two or
more diagnoses that equally meet the definition of principal diagnosis in the
usual instance when two mor more diagnoses equally meet the criteria for
principal diagnosis as determined by the circumstances of admission,
diagnostic workup, and/or therapy provided, and the Alphabetic Index, Tabular
List, or another coding guidelines does not provide sequencing direction, any
one of the diagnoses may be sequenced first.
When physician documentation state Sp02 room air <91%, ABG p02 on room
air less then 60 mm, and proceeds with intubation an/or initiations of BiPAP,
the diagnosis is most likely:
a. Respiratory failure
b. Acute respiratory failure
c. Chronic respiratory failure
d. Acute or chronic respiratory failure - (answer)b. Acute respiratory failure
The respiratory failure can be determined by a partial pressure of oxygen
(Pa02) <60 mmHg with a normal or decreased partial pressure of carbon
dioxide (PaC02). Treatment of respiratory oxygenation and ventilation, as
needed.
Documentation review shows testing of cardiac troponin, echocardiography
with a plan for percutaneous coronary intervention (PCI). The patient is most
likely to be evaluated for:
a. Acute myocardial infarction
b. Chest pain
c. Gastroesophageal reflux disease (GERD)
, 4
d. Cerebrovascular accident (CVA) - (answer)a. Acute myocardial infarction
MI is characterized by presenting with chest discomfort or pressure that can
radiate to the neck, jaw, shoulder, or arm. It can be associated with ECG
changes and elevated biochemical markers; cardiac troponins.
During chart review, it is documented that the patient has sepsis. The CDI
professional should review the labs for testing to identify increased levels of a
substance made by muscle tissue and by red blood cells, which carry oxygen
from the lungs to other parts of the body and can lead to a type of acidosis.
This test is called a:
a. Complete blood count (CBC)
b. Chem 8
c. Kidney function test
d. Lactic acid - (answer)d. Lactic acid
A lactic acid test is utilized in the diagnosis of sepsis.
On CID review, it was noted that the patient stumbled on the sidewalk, and
workup reveals a small pelvic fracture at the symphysis. The MD states she
received Reclast annually. The CDI professional should query for what diagnosis
to reflect complexity and severity?
a. Fracture
b. Osteoporotic fracture
c. Cause of fracture
d. Traumatic fracture - (answer)b. Osteoporotic fracture
A code from category M80, not a traumatic fracture code, should be used for
any patient with known osteoporosis who suffers a fracture, even if the patient
