CDIP Practice Exam 2 LATEST UPDATED|
REAL EXAM QUESTIONS AND
ANSWERS | 100% RATED CORRECT |
100% VERFIED SOLUTIONS | ALREADY
GRADED A+
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 - 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 - 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 - 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 - 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 - 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 - 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 - 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 - 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 - 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) - 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
d.Admitting physical evaluation record - ANSWER a Transfer records are created
whenever a patient is transferred from one facility to another. The transfer record contains a
summary of the care provided in the facility from which the patient is being transferred as well
as the reason for transfer. Transfer records are important to the continuum of care because they
document communication between caregivers in multiple settings (Shaw and Carter 2014;
Fahrenholz and Russo 2013, 225).
A 65-year-old white male was admitted to the hospital on 1/15 complaining of abdominal pain.
The attending physician requested an upper GI series and laboratory evaluation of CBC and UA.
The x-ray revealed possible cholelithiasis and the UA showed an increased white blood cell
count. The patient was taken to surgery for an exploratory laparoscopy and a ruptured appendix
was discovered. The chief complaint was:
a.Ruptured appendix
b.Exploratory laparoscopy
c.Abdominal pain
d.Cholelithiasis - ANSWER c The abdominal pain is the chief complaint and is the
reason the patient presented/reason for visit (Shaw and Carter 2014; Fahrenholz and Russo 2013,
225).
A patient arrived via ambulance to the emergency department following a motor vehicle
accident. The patient sustained a fracture of the ankle, 3.0 cm superficial laceration of the left
arm, 5.0 cm laceration of the scalp with exposure of the fascia, and a concussion. The patient
received the following procedures: x-ray of the ankle that showed a bimalleolar ankle fracture
requiring closed manipulative reduction and simple suturing of the arm laceration and layer
closure of the scalp. Provide CPT codes for the procedures done in the emergency department for
the facility bill.
12002 Simple repair of superficial wounds of scalp, neck, axillae, external genitalia, trunk and/or
extremities (including hands and feet); 2.6 cm to 7.5 cm
12004 Simple repair of superficial wounds of scalp, neck, axillae, external genitalia, trunk and/or
extremities (including hands and feet); 7.6 cm to 12.5 cm
12032 Repair, intermediate, wound - ANSWER c The closed reduction of the fracture
is coded first following principal procedure guidelines. The laceration repair is also coded. When
REAL EXAM QUESTIONS AND
ANSWERS | 100% RATED CORRECT |
100% VERFIED SOLUTIONS | ALREADY
GRADED A+
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 - 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 - 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 - 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 - 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 - 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 - 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 - 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 - 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 - 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) - 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
d.Admitting physical evaluation record - ANSWER a Transfer records are created
whenever a patient is transferred from one facility to another. The transfer record contains a
summary of the care provided in the facility from which the patient is being transferred as well
as the reason for transfer. Transfer records are important to the continuum of care because they
document communication between caregivers in multiple settings (Shaw and Carter 2014;
Fahrenholz and Russo 2013, 225).
A 65-year-old white male was admitted to the hospital on 1/15 complaining of abdominal pain.
The attending physician requested an upper GI series and laboratory evaluation of CBC and UA.
The x-ray revealed possible cholelithiasis and the UA showed an increased white blood cell
count. The patient was taken to surgery for an exploratory laparoscopy and a ruptured appendix
was discovered. The chief complaint was:
a.Ruptured appendix
b.Exploratory laparoscopy
c.Abdominal pain
d.Cholelithiasis - ANSWER c The abdominal pain is the chief complaint and is the
reason the patient presented/reason for visit (Shaw and Carter 2014; Fahrenholz and Russo 2013,
225).
A patient arrived via ambulance to the emergency department following a motor vehicle
accident. The patient sustained a fracture of the ankle, 3.0 cm superficial laceration of the left
arm, 5.0 cm laceration of the scalp with exposure of the fascia, and a concussion. The patient
received the following procedures: x-ray of the ankle that showed a bimalleolar ankle fracture
requiring closed manipulative reduction and simple suturing of the arm laceration and layer
closure of the scalp. Provide CPT codes for the procedures done in the emergency department for
the facility bill.
12002 Simple repair of superficial wounds of scalp, neck, axillae, external genitalia, trunk and/or
extremities (including hands and feet); 2.6 cm to 7.5 cm
12004 Simple repair of superficial wounds of scalp, neck, axillae, external genitalia, trunk and/or
extremities (including hands and feet); 7.6 cm to 12.5 cm
12032 Repair, intermediate, wound - ANSWER c The closed reduction of the fracture
is coded first following principal procedure guidelines. The laceration repair is also coded. When
