CDIP Practice Exam 2 Questions With
Correct Answers
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 |- |CORRECT |ANSWER✔✔-
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 |- |CORRECT |ANSWER✔✔-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 |- |CORRECT |ANSWER✔✔-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 |- |CORRECT |ANSWER✔✔-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 |- |CORRECT |ANSWER✔✔-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 |- |CORRECT |ANSWER✔✔-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 |- |CORRECT |ANSWER✔✔-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 |- |CORRECT |ANSWER✔✔-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 |- |CORRECT |ANSWER✔✔-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) |- |CORRECT |ANSWER✔✔-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
b.Release |of |information |form
c.Patient's |rights |acknowledgment |form
Correct Answers
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 |- |CORRECT |ANSWER✔✔-
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 |- |CORRECT |ANSWER✔✔-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 |- |CORRECT |ANSWER✔✔-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 |- |CORRECT |ANSWER✔✔-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 |- |CORRECT |ANSWER✔✔-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 |- |CORRECT |ANSWER✔✔-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 |- |CORRECT |ANSWER✔✔-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 |- |CORRECT |ANSWER✔✔-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 |- |CORRECT |ANSWER✔✔-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) |- |CORRECT |ANSWER✔✔-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
b.Release |of |information |form
c.Patient's |rights |acknowledgment |form
