Certified Documentation Improvement Practitioner
(CDIP) ACTUAL QUESTIONS AND CORRECT
ANSWERS WITH VERIFIED ANSWERS GRADE 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
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.
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)
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 had a minor fall or trauma, if
that fall or trauma would not usually break a normal, health bone.
On CDI review, it was noted that the patient stumbled on the sidewalk, and workup reveal a
small pelvic fracture at the symphysis. The MD states she received Reclast annually. Which
code category should be used for code category should be used for code assignment?
a. M80
b. M81
c. M82
d. M83 - ANSWER: a. M80
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 had a minor fall or trauma, if
that fall or trauma would not usually break a normal, health bone.
When a patient is admitted with respiratory failure and another acute condition (e.g.,
myocardial infarction, cerebrovascular, aspiration pneumonia), the principal diagnosis will
_____.
(CDIP) ACTUAL QUESTIONS AND CORRECT
ANSWERS WITH VERIFIED ANSWERS GRADE 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
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.
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)
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 had a minor fall or trauma, if
that fall or trauma would not usually break a normal, health bone.
On CDI review, it was noted that the patient stumbled on the sidewalk, and workup reveal a
small pelvic fracture at the symphysis. The MD states she received Reclast annually. Which
code category should be used for code category should be used for code assignment?
a. M80
b. M81
c. M82
d. M83 - ANSWER: a. M80
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 had a minor fall or trauma, if
that fall or trauma would not usually break a normal, health bone.
When a patient is admitted with respiratory failure and another acute condition (e.g.,
myocardial infarction, cerebrovascular, aspiration pneumonia), the principal diagnosis will
_____.
