CDIP EXAM Domain 1
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1. Principal diagnosis (Inpatient): The disease present on admission that received treatment or evalua-
tion during the hospital stay or the reason established after a study to be responsible for the patient's admission
2. Secondary Diagnosis: A statement of those conditions coexisting during a hospital episode that affect
treatment received or length of stay
3. Where to find the pertinent diagnosis: 1. H&P
2. Progress Notes
3. Clinical Notes
4. Operative/Pathology Report
5. Procedure Notes
6. Lab/Radiology Findings
7. Discharge Summary
4. 7 Characteristics of High Quality Clinical Documentation: Clear
Consistent
Complete
Precise
Legible
Timely
Reliable
5. first-listed diagnosis: in the outpatient setting, the primary diagnosis is the main reason for the visit. it is
usually the diagnosis taking the majority of resources for the visit
6. CC: conditions and comorbidities
7. MCC: Major Conditions and Comorbidities
8. Perspective Payment Systems: Predetermined payment based on service provided; began as inpa-
tient but moved to different healthcare areas
9. MSDRG: Medicare Severity Diagnosis Related Groups
10. MDC: Major Diagnostic Category - represents the body systems treated by medicine. (There are 25 MDCs).
Examples: 1) diseases and disorders of the nervous system, 2) diseases and disorders of the eye, 3) infectious and
parasitic diseases, 4) HIV, 5) endocrine & metabolic disorders, 6) pregnancy, childbirth, and the puerperium, etc...
11. ICD-10-CM: International Classification of Diseases, 10th Revision, Clinical Modification
12. ICD-10 Procedure Coding System (ICD-10-PCS): - a system of medical classification used for
procedural codes - for hospital inpatient use only
, CDIP EXAM Domain 1
Study online at https://quizlet.com/_hws6jt
13. Encoder: Specialty software used to facilitate the assignment of diagnostic and procedural codes according to
the rules of the coding system
14. Why use coding software?: Accurate coding
Productivity
Grouping
Edits
Resources
15. Complication: Condition arising during hospital stay that prolongs length of stay by at least 1 day in approx.
75% of cases
16. Comorbidity: A pre-existing condition which because of its presence with the principal diagnosis will increase
the length of stay by at least 1 day in approx. 75% of cases
17. APR-DRG: All Patient Refined Diagnosis-Related Groups
18. Severity of Illness (SOI): extent of physiological decompensation or organ system loss of function.
19. Risk of Mortality (ROM): the likelihood of dying.
20. Four levels to SOI and ROM: 1 = Minor
2 = Moderate
3 = Major
4 = Severe
21. Prospective Payment System Examples: OPPS
HH PPS
SNF PPS
IRF PPS
22. Hopsital outpatient (OPPS): Ambulatory Payment Classifications (APC)
23. Home Health (HH PPS): Outcome and Assessment Information Set (OASIS)
24. Skilled Nursing Facility (SNF PPS): Minimum Data Set (MDS)
25. Inpatient Rehabilitation Facility (IRF PPS): Patient Assessment Instrument (PAI)
26. What impacts MS-DRG assignment?: MS-DRG regulations
CC
MCC
Principal Diagnosis
Secondary Diagnoses
Principal Procedure
Study online at https://quizlet.com/_hws6jt
1. Principal diagnosis (Inpatient): The disease present on admission that received treatment or evalua-
tion during the hospital stay or the reason established after a study to be responsible for the patient's admission
2. Secondary Diagnosis: A statement of those conditions coexisting during a hospital episode that affect
treatment received or length of stay
3. Where to find the pertinent diagnosis: 1. H&P
2. Progress Notes
3. Clinical Notes
4. Operative/Pathology Report
5. Procedure Notes
6. Lab/Radiology Findings
7. Discharge Summary
4. 7 Characteristics of High Quality Clinical Documentation: Clear
Consistent
Complete
Precise
Legible
Timely
Reliable
5. first-listed diagnosis: in the outpatient setting, the primary diagnosis is the main reason for the visit. it is
usually the diagnosis taking the majority of resources for the visit
6. CC: conditions and comorbidities
7. MCC: Major Conditions and Comorbidities
8. Perspective Payment Systems: Predetermined payment based on service provided; began as inpa-
tient but moved to different healthcare areas
9. MSDRG: Medicare Severity Diagnosis Related Groups
10. MDC: Major Diagnostic Category - represents the body systems treated by medicine. (There are 25 MDCs).
Examples: 1) diseases and disorders of the nervous system, 2) diseases and disorders of the eye, 3) infectious and
parasitic diseases, 4) HIV, 5) endocrine & metabolic disorders, 6) pregnancy, childbirth, and the puerperium, etc...
11. ICD-10-CM: International Classification of Diseases, 10th Revision, Clinical Modification
12. ICD-10 Procedure Coding System (ICD-10-PCS): - a system of medical classification used for
procedural codes - for hospital inpatient use only
, CDIP EXAM Domain 1
Study online at https://quizlet.com/_hws6jt
13. Encoder: Specialty software used to facilitate the assignment of diagnostic and procedural codes according to
the rules of the coding system
14. Why use coding software?: Accurate coding
Productivity
Grouping
Edits
Resources
15. Complication: Condition arising during hospital stay that prolongs length of stay by at least 1 day in approx.
75% of cases
16. Comorbidity: A pre-existing condition which because of its presence with the principal diagnosis will increase
the length of stay by at least 1 day in approx. 75% of cases
17. APR-DRG: All Patient Refined Diagnosis-Related Groups
18. Severity of Illness (SOI): extent of physiological decompensation or organ system loss of function.
19. Risk of Mortality (ROM): the likelihood of dying.
20. Four levels to SOI and ROM: 1 = Minor
2 = Moderate
3 = Major
4 = Severe
21. Prospective Payment System Examples: OPPS
HH PPS
SNF PPS
IRF PPS
22. Hopsital outpatient (OPPS): Ambulatory Payment Classifications (APC)
23. Home Health (HH PPS): Outcome and Assessment Information Set (OASIS)
24. Skilled Nursing Facility (SNF PPS): Minimum Data Set (MDS)
25. Inpatient Rehabilitation Facility (IRF PPS): Patient Assessment Instrument (PAI)
26. What impacts MS-DRG assignment?: MS-DRG regulations
CC
MCC
Principal Diagnosis
Secondary Diagnoses
Principal Procedure
