IAHCSMM Clinical Documentation
Improvement CDS 2024 Exam Review
Questions and Answers 100% Pass |
Graded A+
David Mungai [Date] [Course title]
, IAHCSMM Clinical Documentation
Improvement CDS 2024 Exam Review
Questions and Answers 100% Pass |
Graded A+
Which of the following do not usually perform the function of
clinical documentation improvement? - Answer>> auditors
Clinical documentation improvement reviews are performed
_____. - Answer>> both concurrently and retrospectively
What should a coder do when a CC or MCC is inferred from
treatment, testing, and other documentation but not clearly
documented as a diagnosis? - Answer>> initiate a post-
discharge query
Optimal DRG assignment is based on _____. - Answer>>
principal diagnosis, procedures performed, and certain secondary
diagnoses
Coding maximization is sometimes called _____. - Answer>>
upcoding
True/False: - Answer>>
The use of yes/no physician queries is encouraged. - Answer>>
False
Strong coders keep an eye toward getting the facility the highest
legitimate reimbursement through coding optimization. -
Answer>> True
,A patient is admitted from the emergency department (ED) with a
diagnosis of weakness and anemia. After admission and further
treatment with packed red blood cells (PRBC), GI consult, and
endoscopy, the physician includes the following diagnoses in the
discharge summary: anemia, suspected bleeding gastric ulcer,
and GERD. What would be the most appropriate principle
diagnosis?
A. Bleeding gastric ulcer
B. Anemia
C. GERD
D. Weakness - Answer>> A. Bleeding gastric ulcer
A patient is admitted with new-onset seizures. Head CT reveals a
mass in the occipital region. The physician documents possible
brain tumor, and the patient is transferred to another hospital for
further workup. What would be the most appropriate principal
diagnosis based upon this documentation?
A. Seizure
B. Neoplasm of occipital region
C. Head mass
D. Head tumor - Answer>> B. Neoplasm of occipital region
A hospital's base rate or blended rate is:
1. Calculated annually
2. Dependent upon indirect costs for graduate medical education
and new technology
3. Adjusted based upon number of low-income patients cared for
4. Not adjusted based upon capital expenses
A. 1 and 2
B. 2 and 3
C. 1,2, and 3
, D. 1,2,3, and 4 - Answer>> C. 1,2, and 3
1. Calculated annually
2. Dependent upon indirect costs for graduate medical education
and new technology
3. Adjusted based upon number of low-income patients cared for
The final MS-DRG assigned to a patient's medical record should:
A. Reflect the amount of time the physician spent with the patient
B. Depend upon the patient's length of stay
C. Be assigned by the physician
D. Reflect the severity of illness (SOI) and resource consumption
of the patient's care - Answer>> D. Reflect the severity of illness
(SOI) and resource consumption of the patient's care
A patient is admitted from the emergency department with the
diagnosis of acute respiratory failure due to overdose of pain
medication and an aspiration pneumonia. What is the principal
diagnosis?
A. Acute respiratory failure
B. Aspiration pneumonia
C. Poisoning
D. Adverse effect of medication - Answer>> C. Poisoning
A patient is admitted with pneumonia, stage 1 chronic renal
failure, chronic anemia, and COPD, While hospitalized the patient
receives IV antibiotics, inhalers, oxygen, IV fluids at 50mL/hr, and
iron tablets. Keeping the guidelines for coding of secondary
diagnoses in mind, which condition should be coded?
A. Pneumonia only
B. Pneumonia and COPD only
C. Pneumonia, COPD, and anemia
Improvement CDS 2024 Exam Review
Questions and Answers 100% Pass |
Graded A+
David Mungai [Date] [Course title]
, IAHCSMM Clinical Documentation
Improvement CDS 2024 Exam Review
Questions and Answers 100% Pass |
Graded A+
Which of the following do not usually perform the function of
clinical documentation improvement? - Answer>> auditors
Clinical documentation improvement reviews are performed
_____. - Answer>> both concurrently and retrospectively
What should a coder do when a CC or MCC is inferred from
treatment, testing, and other documentation but not clearly
documented as a diagnosis? - Answer>> initiate a post-
discharge query
Optimal DRG assignment is based on _____. - Answer>>
principal diagnosis, procedures performed, and certain secondary
diagnoses
Coding maximization is sometimes called _____. - Answer>>
upcoding
True/False: - Answer>>
The use of yes/no physician queries is encouraged. - Answer>>
False
Strong coders keep an eye toward getting the facility the highest
legitimate reimbursement through coding optimization. -
Answer>> True
,A patient is admitted from the emergency department (ED) with a
diagnosis of weakness and anemia. After admission and further
treatment with packed red blood cells (PRBC), GI consult, and
endoscopy, the physician includes the following diagnoses in the
discharge summary: anemia, suspected bleeding gastric ulcer,
and GERD. What would be the most appropriate principle
diagnosis?
A. Bleeding gastric ulcer
B. Anemia
C. GERD
D. Weakness - Answer>> A. Bleeding gastric ulcer
A patient is admitted with new-onset seizures. Head CT reveals a
mass in the occipital region. The physician documents possible
brain tumor, and the patient is transferred to another hospital for
further workup. What would be the most appropriate principal
diagnosis based upon this documentation?
A. Seizure
B. Neoplasm of occipital region
C. Head mass
D. Head tumor - Answer>> B. Neoplasm of occipital region
A hospital's base rate or blended rate is:
1. Calculated annually
2. Dependent upon indirect costs for graduate medical education
and new technology
3. Adjusted based upon number of low-income patients cared for
4. Not adjusted based upon capital expenses
A. 1 and 2
B. 2 and 3
C. 1,2, and 3
, D. 1,2,3, and 4 - Answer>> C. 1,2, and 3
1. Calculated annually
2. Dependent upon indirect costs for graduate medical education
and new technology
3. Adjusted based upon number of low-income patients cared for
The final MS-DRG assigned to a patient's medical record should:
A. Reflect the amount of time the physician spent with the patient
B. Depend upon the patient's length of stay
C. Be assigned by the physician
D. Reflect the severity of illness (SOI) and resource consumption
of the patient's care - Answer>> D. Reflect the severity of illness
(SOI) and resource consumption of the patient's care
A patient is admitted from the emergency department with the
diagnosis of acute respiratory failure due to overdose of pain
medication and an aspiration pneumonia. What is the principal
diagnosis?
A. Acute respiratory failure
B. Aspiration pneumonia
C. Poisoning
D. Adverse effect of medication - Answer>> C. Poisoning
A patient is admitted with pneumonia, stage 1 chronic renal
failure, chronic anemia, and COPD, While hospitalized the patient
receives IV antibiotics, inhalers, oxygen, IV fluids at 50mL/hr, and
iron tablets. Keeping the guidelines for coding of secondary
diagnoses in mind, which condition should be coded?
A. Pneumonia only
B. Pneumonia and COPD only
C. Pneumonia, COPD, and anemia
