CDIP Practice Exam 2 WITH ANSWERS |\ |\ |\ |\ |\
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 ANSWERS ✔✔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 ANSWERS ✔✔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 ANSWERS ✔✔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 ANSWERS ✔✔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 ANSWERS ✔✔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 ANSWERS ✔✔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 ANSWERS ✔✔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 |\ |\ |\ |\ |\ |\ |\ |\ |\
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 ANSWERS ✔✔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 ANSWERS ✔✔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 ANSWERS ✔✔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 ANSWERS ✔✔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 ANSWERS ✔✔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 ANSWERS ✔✔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 ANSWERS ✔✔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 |\ |\ |\ |\ |\ |\ |\ |\ |\
