CDIP Prac ce Exam 1 COMBINED WITH AHIMA Prac ce
Exam 1 With complete solu on Newest RATED A+
2025/2026 NEW!!
A 30-year-old cerebral palsy pa ent was admi ed with acute bronchi s, possible pneumonia. In
reviewing the diagnoses below what addi onally will impact the pa ent's ICD-10 code
assignment.
a.Spas city
b.Quadriplegia
c.Both A and B
d.None of the above - Answers c ICD-10 Cerebral palsy and other paraly c syndromes (G80-
G83) has addi onal specificity for spas city as well as state of paralysis if any (AHIMA 2015, 23).
A 32-year-old female fractured her ankle when she stumbled over the shopping cart while
pushing it in the supermarket. The orthopedic surgeon recommended open fusion of the right
ankle with direct internal fixa on, which was performed. Complete the coding of this procedure
using the chart below
OSGF _ _ _
ApproachDeviceQualifier0 Open4 Internal Fixa on DeviceZ No Qualifier3 Percutaneous5
External Fixa on Device4 Percutaneous endoscopic7 Autologous Tissues Subs tuteJ Synthe c
Subs tuteK Nonautologous Tissues Subs tuteZ No device
a.OSGF34Z
b.OSGF05Z
c.OSGF04Z
d.OSGF35Z - Answers c The correct code assignment for Fusion of the right ankle open with
internal fixa on is OSGF04Z (Leon-Chisen 2013, 102).
A 32-year-old female had a liver transplant 2 years ago. She has been experiencing problems
with her kidneys with a GFR of 20 and Stage IV CKD. She is noted to have some jaundice. Based
on this:
,a.Query should be performed for complica on of liver transplant
b.Query should be performed for rejec on of liver transplant
c.Query should not be performed as there are no liver complica ons
d.No addi onal documenta on needed for repor ng - Answers a It is noted that the pa ent
has a previous liver transplant and experiencing jaundice. If a transplant complica on such as
failure or rejec on or other transplant complica on is documented, see sec on I.C. 19.g for
informa on on coding complica ons of a kidney transplant. If the documenta on is unclear as
to whether the pa ent has a complica on of the transplant, query the provider (ICD-10-CM
Official Guidelines for Coding and Repor ng 2016b, 52).
A 60-year-old female was admi ed with hip fracture and replacement was planned. On day
three of admission it was noted that the conges ve heart failure (CHF) with shortness of breath
and 3+ pedal edema. The pa ent was started on IV Lasix at 40 mg. The physician states
admission for CHF and fracture of hip on the discharge summary. The CDS performed a query
sta ng-Pa ent treated with 40 mg Lasix. Please document Acute CHF.
This query is
a.Non-leading and appropriate
b.Leading and inappropriate - Answers b This query is leading in asking the physician
specifically what to document. A leading query is one that is not supported by the clinical
elements in the health record or directs a provider to a specific diagnosis or procedure (AHIMA
2013b, 50-53).
A 65-year-old male was admi ed with GI (gastrointes nal) bleed and was administered 2 units
of packed red blood cells. The physician documented acute GI bleed. The CDS performed a
query sta ng, 'Pa ent noted to have acute GI bleed treated with transfusion." Is this blood loss
anemia?
This query is
a.Non-leading and appropriate
b.Leading and inappropriate - Answers b This query is leading in asking the physician
specifically what to document. A leading query is one that is not supported by the clinical
elements in the health record or directs a provider to a specific diagnosis or procedure (AHIMA
2013b, 50-53).
,A 90-year-old female was determined to have a CVA with hemorrhage. The cause of the
hemorrhage was determined to be an embolism. What addi onally could impact code
assignment for the embolism code?
a.Hematemesis
b.Hypertension
c.Site of the hemorrhage
d.Seizure - Answers c ICD-10 includes the site of the of the hemorrhage for increased
specificity.
A CDI program should allow concurrent documenta on review to:
a.educate clinical care providers
b.allow providers to clarify hospital acquired condi ons and present on admission indicators
c.address areas of quality impact
d.all of the above - Answers d Queries should address areas of quality impact such as present
on admission indicators and hospital acquired condi ons (Hess 2015, 234).
A CDI program should have
a.Training
b.Physician advisor or champion
c.Nurses or coders performing CDI review
d.None of the above - Answers b A physician advisor/champion should be officially designated
as the physician leader for CDI (Hess 2015, 122).
A coder notes that the pa ent is taking prescribed Haldol. The final diagnoses on the progress
notes include diabetes mellitus, acute pharyngi s, and malnutri on. What condi on might the
coder suspect the pa ent has that the physician should be queried to confirm?
a.Insomnia
, b.Hypertension
c.Mental or behavioral problems
d.Rheumatoid arthri s - Answers c Haldol is a drug frequently administered for behavior or
mental condi ons, so the coder would suspect mental or behavioral problems for this pa ent.
The physician must be queried to confirm the diagnosis. Documenta on is needed in the record
to support the coding of the mental or behavioral problem (Shaw and Carter 2014;
Schraffenberger and Kuehn 2011, 285).
A compliant CDI program should have components to include
a.Documented, mandatory physician educa on
b.Detailed query documenta on
c.CDI policies and procedures with annual sign-off from all program staff
d.All of the above - Answers d A compliant CDI program should have components to include
documented, mandatory physician educa on as they are ul mately responsible for the
documenta on, detailed query documenta on for compliance, and CDI policies and procedures
with annual sign-off from all program staff to ensure correct messaging of informa on (Hess
2015, 208).
A facility has a MSDRG u liza on rate of 85% of MCCs for a specific MSDRG. This could indicate:
a.underu liza on
b.overu liza on
c.a compliance risk
d.both Band C - Answers d A higher u liza on of a specific DRG in comparison to peers could
indicate a documenta on/coding issue (Hess 2015, 90).
A new CDI program is experiencing conflicts within the health record between a consul ng
physician and the physician ul mately responsible for the documenta on of the pa ent. The
physician ul mately responsible is the:
a.Consul ng physician
Exam 1 With complete solu on Newest RATED A+
2025/2026 NEW!!
A 30-year-old cerebral palsy pa ent was admi ed with acute bronchi s, possible pneumonia. In
reviewing the diagnoses below what addi onally will impact the pa ent's ICD-10 code
assignment.
a.Spas city
b.Quadriplegia
c.Both A and B
d.None of the above - Answers c ICD-10 Cerebral palsy and other paraly c syndromes (G80-
G83) has addi onal specificity for spas city as well as state of paralysis if any (AHIMA 2015, 23).
A 32-year-old female fractured her ankle when she stumbled over the shopping cart while
pushing it in the supermarket. The orthopedic surgeon recommended open fusion of the right
ankle with direct internal fixa on, which was performed. Complete the coding of this procedure
using the chart below
OSGF _ _ _
ApproachDeviceQualifier0 Open4 Internal Fixa on DeviceZ No Qualifier3 Percutaneous5
External Fixa on Device4 Percutaneous endoscopic7 Autologous Tissues Subs tuteJ Synthe c
Subs tuteK Nonautologous Tissues Subs tuteZ No device
a.OSGF34Z
b.OSGF05Z
c.OSGF04Z
d.OSGF35Z - Answers c The correct code assignment for Fusion of the right ankle open with
internal fixa on is OSGF04Z (Leon-Chisen 2013, 102).
A 32-year-old female had a liver transplant 2 years ago. She has been experiencing problems
with her kidneys with a GFR of 20 and Stage IV CKD. She is noted to have some jaundice. Based
on this:
,a.Query should be performed for complica on of liver transplant
b.Query should be performed for rejec on of liver transplant
c.Query should not be performed as there are no liver complica ons
d.No addi onal documenta on needed for repor ng - Answers a It is noted that the pa ent
has a previous liver transplant and experiencing jaundice. If a transplant complica on such as
failure or rejec on or other transplant complica on is documented, see sec on I.C. 19.g for
informa on on coding complica ons of a kidney transplant. If the documenta on is unclear as
to whether the pa ent has a complica on of the transplant, query the provider (ICD-10-CM
Official Guidelines for Coding and Repor ng 2016b, 52).
A 60-year-old female was admi ed with hip fracture and replacement was planned. On day
three of admission it was noted that the conges ve heart failure (CHF) with shortness of breath
and 3+ pedal edema. The pa ent was started on IV Lasix at 40 mg. The physician states
admission for CHF and fracture of hip on the discharge summary. The CDS performed a query
sta ng-Pa ent treated with 40 mg Lasix. Please document Acute CHF.
This query is
a.Non-leading and appropriate
b.Leading and inappropriate - Answers b This query is leading in asking the physician
specifically what to document. A leading query is one that is not supported by the clinical
elements in the health record or directs a provider to a specific diagnosis or procedure (AHIMA
2013b, 50-53).
A 65-year-old male was admi ed with GI (gastrointes nal) bleed and was administered 2 units
of packed red blood cells. The physician documented acute GI bleed. The CDS performed a
query sta ng, 'Pa ent noted to have acute GI bleed treated with transfusion." Is this blood loss
anemia?
This query is
a.Non-leading and appropriate
b.Leading and inappropriate - Answers b This query is leading in asking the physician
specifically what to document. A leading query is one that is not supported by the clinical
elements in the health record or directs a provider to a specific diagnosis or procedure (AHIMA
2013b, 50-53).
,A 90-year-old female was determined to have a CVA with hemorrhage. The cause of the
hemorrhage was determined to be an embolism. What addi onally could impact code
assignment for the embolism code?
a.Hematemesis
b.Hypertension
c.Site of the hemorrhage
d.Seizure - Answers c ICD-10 includes the site of the of the hemorrhage for increased
specificity.
A CDI program should allow concurrent documenta on review to:
a.educate clinical care providers
b.allow providers to clarify hospital acquired condi ons and present on admission indicators
c.address areas of quality impact
d.all of the above - Answers d Queries should address areas of quality impact such as present
on admission indicators and hospital acquired condi ons (Hess 2015, 234).
A CDI program should have
a.Training
b.Physician advisor or champion
c.Nurses or coders performing CDI review
d.None of the above - Answers b A physician advisor/champion should be officially designated
as the physician leader for CDI (Hess 2015, 122).
A coder notes that the pa ent is taking prescribed Haldol. The final diagnoses on the progress
notes include diabetes mellitus, acute pharyngi s, and malnutri on. What condi on might the
coder suspect the pa ent has that the physician should be queried to confirm?
a.Insomnia
, b.Hypertension
c.Mental or behavioral problems
d.Rheumatoid arthri s - Answers c Haldol is a drug frequently administered for behavior or
mental condi ons, so the coder would suspect mental or behavioral problems for this pa ent.
The physician must be queried to confirm the diagnosis. Documenta on is needed in the record
to support the coding of the mental or behavioral problem (Shaw and Carter 2014;
Schraffenberger and Kuehn 2011, 285).
A compliant CDI program should have components to include
a.Documented, mandatory physician educa on
b.Detailed query documenta on
c.CDI policies and procedures with annual sign-off from all program staff
d.All of the above - Answers d A compliant CDI program should have components to include
documented, mandatory physician educa on as they are ul mately responsible for the
documenta on, detailed query documenta on for compliance, and CDI policies and procedures
with annual sign-off from all program staff to ensure correct messaging of informa on (Hess
2015, 208).
A facility has a MSDRG u liza on rate of 85% of MCCs for a specific MSDRG. This could indicate:
a.underu liza on
b.overu liza on
c.a compliance risk
d.both Band C - Answers d A higher u liza on of a specific DRG in comparison to peers could
indicate a documenta on/coding issue (Hess 2015, 90).
A new CDI program is experiencing conflicts within the health record between a consul ng
physician and the physician ul mately responsible for the documenta on of the pa ent. The
physician ul mately responsible is the:
a.Consul ng physician
