CDIP PRACTICE EXAM 2 2025 WITH ACTUAL
CORRECT QUESTIONS AND VERIFIED
DETAILED RATIONALES ANSWERS
|FREQUENTLY TESTED QUESTIONS AND
SOLUTIONS |ALREADY GRADED A+|LATEST
UPDATE|GUARANTEED PASS
The CDI manager at Star Hospital has been concerned about the hospital quality ratings over
the past 2 years. She has been focused on educating physicians on documentation and working
with CDS staff on hospital acquired conditions, MCC/CC capture. She may also want to educate
regarding which area below to increase quality score:
a.The principal diagnosis
b.The principal procedure
c.SOI
d.None of the above
c It is beneficial for hospitals to monitor severity levels. It has been determined that better
quality ratings if the majority of their inpatients are in higher severity group levels (Hess 2015,
197).
Ms. Smith is admitted with shortness of breath, cough, wheezing, and tachypnea. She had been
on handheld bronchodilators, and has a history of chronic obstructive pulmonary disease
(COPD). Treatment as an inpatient includes Prednisone, nebulizer treatment, and oxygen at 80
percent.
Based on presentation and treatment, this could potentially be a query for:
a.Pneumonia
b.Acute lung injury
c.COPD exacerbation
d.Nothing; no need to query
1|Page
,c The patient has a documented diagnosis of COPD and clinical indicators, and treatment that
exhibit increased severity and reflection of current state of disease with a query for
exacerbation. This is consistent with When and How to Query The generation of a query
should be considered when the health record documentation:
•Is conflicting, imprecise, incomplete, illegible, ambiguous, or inconsistent
•Describes or is associated with clinical indicators without a definitive relationship to an
underlying diagnosis
•Includes clinical indicators, diagnostic evaluation, and/or treatment not related to a specific
condition or procedure
•Provides a diagnosis without underlying clinical validation
•Is unclear for present on admission indicator assignment
All documentation entered in the medical record relating to the patient's diagnosis and
treatment are considered this type of data:
a.Clinical
b.Identification
c.Secondary
d.Financial
a Basic clinical data, such as the type of surgery or reason for the visit, is collected and
recorded during the intake process. From this, the treating or admitting physician can provide
the patient's preliminary diagnosis and the reason the patient is seeking treatment. Accurate
clinical data collection is important because it becomes the basis of care plans and helps
determine medical necessity (Shaw and Carter 2014; Fahrenholz and Russo 2013, 77).
Data that have been grouped into meaningful categories according to a classification system are
referred to as ________ data.
a.Research
b.Reference
c.Coded
d.Demographic
c Coded data is data that is translated into standard nomenclature of classification so that it
may be aggregated, analyzed, and compared (Shaw and Carter 2014; LaTour et al. 2013, 903).
The Glasgow Coma Scale provides an objective assessment of a patient's level of consciousness
for specific dates and times. If a patient's scores are outside of the normal range and no
corresponding neurological diagnosis is present, the CDS should:
a.Not be concerned with this clinical finding.
b.Initiate a query to clarify the report findings.
2|Page
,c.Query for altered mental status.
d.Assign a code for abnormal findings on examination.
b The Glasgow Coma Scale are often found within the Neurological Flowsheet or other Neuro
Assessment documents, provides an objective assessment of a patient's level of
consciousness for specific dates and times. Where scores are beyond the normal ranges and
no corresponding neurological diagnosis is present, the coder should query the physician
(Hess 2015, 19).
Dr. Smith, internal medicine, is the attending physician and his documentation is conflicting with
the diagnosis of GI bleed made by the gastroenterologist with no blood on exam. Query is
performed due to this conflicting diagnosis. In response to query, Dr. Smith states no history of
or present GI bleed. The CDS should:
a.Code GI bleed as documented
b.Ignore the query
c.Utilize the clarification provided by the attending physician for coding
d.Code the diagnosis made by the specialist as he would know more about the bleed
c Where there is consistent provider documentation within the record, medical coders can use
other parts of the record for final coding. Where there is provider disagreement on the
diagnoses or the diagnosis is unclear, coders must always submit a query to clarify. If the two
providers cannot agree, the medical coder always uses the attending physician's diagnosis for
final coding. Coders must consider a query if the clinical record
•Is conflicting, imprecise, incomplete, illegible, ambiguous, or inconsistent
•Describes or is associated with clinical indicators without a definitive relationship to an
underlying diagnosis
•Includes clinical indicators, diagnostic evaluation, or treatment unrelated to a specific
condition or procedure
•Provides a diagnosis without underlying clinical validation
•Is unclear about present on admission indicator (POA)
A patient presents through the ED and was admitted with wheezing, peripheral edema, with a
history of underlying ischemic heart disease and an ejection fraction of less than 45 percent. X-
ray shows pulmonary edema with elevated BNP B-type Natriuretic Peptide). The patient was
started with diuresis. The physician documents CHF, congestive heart failure. Based on the
above, query should be performed for:
a.Pulmonary congestion
b.The type and location of the CHF
c.No query is needed
d.None of the above
3|Page
, b The physician documents CHF exhibiting acute phase of this chronic condition. A physician
query is a question directed to a physician to obtain clarification of documentation in a
patient's record when the current documentation does not meet one or more of the criteria
for high-quality clinical documentation. Therefore, the patient's record must contain clinical
evidence to support any questions (or queries) the CDI specialist asks the physician regarding
documentation in that record (Hess 2015, 176).
A patient presents with delirium. The patient has a strong smell of alcohol, and family member
states the patient has been drinking alcohol all day. Alcohol levels are reported to be outside of
the normal limits. The physician documents acute alcohol intoxication with delirium. Based on
this, is it appropriate to query for metabolic encephalopathy?
a.Yes, a query is warranted for metabolic encephalopathy.
b.No, a query is not warranted for metabolic encephalopathy.
c.Assign the diagnosis of metabolic encephalopathy without query.
d.Query for CVA.
b The patient has acute alcohol intoxication with delirium. "Metabolic encephalopathy is
always due to an underlying cause. There are many causes of metabolic encephalopathy, such
as brain tumors, brain metastasis, cerebral infarction or hemorrhage, cerebral ischemia,
uremia, poisoning, systemic infection, etc. Metabolic encephalopathy is also a common
finding in 12-33% of patients suffering from multiple organ failure. The development of
metabolic encephalopathy may be the first manifestation of a critical systemic illness and may
be caused by various reasons—one of the most important being sepsis" (AHA Fourth Quarter
2003, 58-59).
After a 10-day admission, the physician dictates a discharge summary. The patient, an 86-year-
old female, presented with CVA with bleed confirmed on MRI. The patient was noted to have
some residual problems with movement on the right side and drawing of the face on the right
side with some difficulty speaking. It was decided the patient would have a swallowing test
performed on day 5 of admission prior to discharge due to concerns by speech therapy. Prior to
evaluation and on the day of initial planned discharge, it was noted that the patient had a fever,
dyspnea, tachypnea with some crackles and rales in the bases. Fever was 101.1 degrees with
WBCs of 13,000, with no cultures, and consolidation on chest x-ray. Patient's final diagnosis is
CVA with hemorrhage, chronic COPD, diabetes. Plan to see patient in the office in 7 days from
home. Based on the information above, it would be appropriate to query for:
a.Gram neg
c Pneumonia Documentation Suggestions: Describe clinical signs and symptoms (e.g., fever,
chills, cough, dyspnea, tachypnea, crackles or rales, etc).
Note radiological and laboratory findings - include rationale for disagreement with any findings
4|Page
CORRECT QUESTIONS AND VERIFIED
DETAILED RATIONALES ANSWERS
|FREQUENTLY TESTED QUESTIONS AND
SOLUTIONS |ALREADY GRADED A+|LATEST
UPDATE|GUARANTEED PASS
The CDI manager at Star Hospital has been concerned about the hospital quality ratings over
the past 2 years. She has been focused on educating physicians on documentation and working
with CDS staff on hospital acquired conditions, MCC/CC capture. She may also want to educate
regarding which area below to increase quality score:
a.The principal diagnosis
b.The principal procedure
c.SOI
d.None of the above
c It is beneficial for hospitals to monitor severity levels. It has been determined that better
quality ratings if the majority of their inpatients are in higher severity group levels (Hess 2015,
197).
Ms. Smith is admitted with shortness of breath, cough, wheezing, and tachypnea. She had been
on handheld bronchodilators, and has a history of chronic obstructive pulmonary disease
(COPD). Treatment as an inpatient includes Prednisone, nebulizer treatment, and oxygen at 80
percent.
Based on presentation and treatment, this could potentially be a query for:
a.Pneumonia
b.Acute lung injury
c.COPD exacerbation
d.Nothing; no need to query
1|Page
,c The patient has a documented diagnosis of COPD and clinical indicators, and treatment that
exhibit increased severity and reflection of current state of disease with a query for
exacerbation. This is consistent with When and How to Query The generation of a query
should be considered when the health record documentation:
•Is conflicting, imprecise, incomplete, illegible, ambiguous, or inconsistent
•Describes or is associated with clinical indicators without a definitive relationship to an
underlying diagnosis
•Includes clinical indicators, diagnostic evaluation, and/or treatment not related to a specific
condition or procedure
•Provides a diagnosis without underlying clinical validation
•Is unclear for present on admission indicator assignment
All documentation entered in the medical record relating to the patient's diagnosis and
treatment are considered this type of data:
a.Clinical
b.Identification
c.Secondary
d.Financial
a Basic clinical data, such as the type of surgery or reason for the visit, is collected and
recorded during the intake process. From this, the treating or admitting physician can provide
the patient's preliminary diagnosis and the reason the patient is seeking treatment. Accurate
clinical data collection is important because it becomes the basis of care plans and helps
determine medical necessity (Shaw and Carter 2014; Fahrenholz and Russo 2013, 77).
Data that have been grouped into meaningful categories according to a classification system are
referred to as ________ data.
a.Research
b.Reference
c.Coded
d.Demographic
c Coded data is data that is translated into standard nomenclature of classification so that it
may be aggregated, analyzed, and compared (Shaw and Carter 2014; LaTour et al. 2013, 903).
The Glasgow Coma Scale provides an objective assessment of a patient's level of consciousness
for specific dates and times. If a patient's scores are outside of the normal range and no
corresponding neurological diagnosis is present, the CDS should:
a.Not be concerned with this clinical finding.
b.Initiate a query to clarify the report findings.
2|Page
,c.Query for altered mental status.
d.Assign a code for abnormal findings on examination.
b The Glasgow Coma Scale are often found within the Neurological Flowsheet or other Neuro
Assessment documents, provides an objective assessment of a patient's level of
consciousness for specific dates and times. Where scores are beyond the normal ranges and
no corresponding neurological diagnosis is present, the coder should query the physician
(Hess 2015, 19).
Dr. Smith, internal medicine, is the attending physician and his documentation is conflicting with
the diagnosis of GI bleed made by the gastroenterologist with no blood on exam. Query is
performed due to this conflicting diagnosis. In response to query, Dr. Smith states no history of
or present GI bleed. The CDS should:
a.Code GI bleed as documented
b.Ignore the query
c.Utilize the clarification provided by the attending physician for coding
d.Code the diagnosis made by the specialist as he would know more about the bleed
c Where there is consistent provider documentation within the record, medical coders can use
other parts of the record for final coding. Where there is provider disagreement on the
diagnoses or the diagnosis is unclear, coders must always submit a query to clarify. If the two
providers cannot agree, the medical coder always uses the attending physician's diagnosis for
final coding. Coders must consider a query if the clinical record
•Is conflicting, imprecise, incomplete, illegible, ambiguous, or inconsistent
•Describes or is associated with clinical indicators without a definitive relationship to an
underlying diagnosis
•Includes clinical indicators, diagnostic evaluation, or treatment unrelated to a specific
condition or procedure
•Provides a diagnosis without underlying clinical validation
•Is unclear about present on admission indicator (POA)
A patient presents through the ED and was admitted with wheezing, peripheral edema, with a
history of underlying ischemic heart disease and an ejection fraction of less than 45 percent. X-
ray shows pulmonary edema with elevated BNP B-type Natriuretic Peptide). The patient was
started with diuresis. The physician documents CHF, congestive heart failure. Based on the
above, query should be performed for:
a.Pulmonary congestion
b.The type and location of the CHF
c.No query is needed
d.None of the above
3|Page
, b The physician documents CHF exhibiting acute phase of this chronic condition. A physician
query is a question directed to a physician to obtain clarification of documentation in a
patient's record when the current documentation does not meet one or more of the criteria
for high-quality clinical documentation. Therefore, the patient's record must contain clinical
evidence to support any questions (or queries) the CDI specialist asks the physician regarding
documentation in that record (Hess 2015, 176).
A patient presents with delirium. The patient has a strong smell of alcohol, and family member
states the patient has been drinking alcohol all day. Alcohol levels are reported to be outside of
the normal limits. The physician documents acute alcohol intoxication with delirium. Based on
this, is it appropriate to query for metabolic encephalopathy?
a.Yes, a query is warranted for metabolic encephalopathy.
b.No, a query is not warranted for metabolic encephalopathy.
c.Assign the diagnosis of metabolic encephalopathy without query.
d.Query for CVA.
b The patient has acute alcohol intoxication with delirium. "Metabolic encephalopathy is
always due to an underlying cause. There are many causes of metabolic encephalopathy, such
as brain tumors, brain metastasis, cerebral infarction or hemorrhage, cerebral ischemia,
uremia, poisoning, systemic infection, etc. Metabolic encephalopathy is also a common
finding in 12-33% of patients suffering from multiple organ failure. The development of
metabolic encephalopathy may be the first manifestation of a critical systemic illness and may
be caused by various reasons—one of the most important being sepsis" (AHA Fourth Quarter
2003, 58-59).
After a 10-day admission, the physician dictates a discharge summary. The patient, an 86-year-
old female, presented with CVA with bleed confirmed on MRI. The patient was noted to have
some residual problems with movement on the right side and drawing of the face on the right
side with some difficulty speaking. It was decided the patient would have a swallowing test
performed on day 5 of admission prior to discharge due to concerns by speech therapy. Prior to
evaluation and on the day of initial planned discharge, it was noted that the patient had a fever,
dyspnea, tachypnea with some crackles and rales in the bases. Fever was 101.1 degrees with
WBCs of 13,000, with no cultures, and consolidation on chest x-ray. Patient's final diagnosis is
CVA with hemorrhage, chronic COPD, diabetes. Plan to see patient in the office in 7 days from
home. Based on the information above, it would be appropriate to query for:
a.Gram neg
c Pneumonia Documentation Suggestions: Describe clinical signs and symptoms (e.g., fever,
chills, cough, dyspnea, tachypnea, crackles or rales, etc).
Note radiological and laboratory findings - include rationale for disagreement with any findings
4|Page
