CDIP Practice Exam 2 with 100% Correct
Answers 2023/2024
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 - Correct 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 - Correct 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 - Correct 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 - Correct 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 - Correct 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 - Correct 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 - Correct 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 - Correct 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 - Correct 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) - Correct 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 - Correct 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 - Correct 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, wounds of scalp, axillae, trunk and/or extremities
(excluding hands and feet); 2.6 cm to 7.5 cm
27810 Closed treatment of bimalleolar ankle fracture (e.g., lateral and medial malleoli,
or lateral and posterior malleoli, or medial and posterior malleoli); with manipulation
27818 Closed treatment of trimalleolar ankle fracture; with manipulation
a.27810, 12032
b.27818, 12004, 12032
c.27810, 12032, 12002
d.27810, 12004 - Correct answer-c The closed reduction of the fracture is coded first
following principal procedure guidelines. The laceration repair is also coded. When
more than one classification of wound repair is performed, all codes are reported with
the code for the most complicated procedure listed first (Kuehn 2013, 26-27, 111-113).
The appeal coordinator received a denial that stated: On presentation, patient had
hemoglobin of 8.8 with blood in stool noted in physician office...patient sent as direct
admission straight to hospital. The physician notes 11/05/14 states GI bleeding will
consider transfusion 11/06/14. Note also states melenic stools and states hemoccult
positive. Endoscopy report states - Acute Posthemorrhagic Anemia with iron deficiency
anemia due to blood loss. "Multiple small angioectasias without bleeding were found in
the second part of the duodenum. Red blood was found on the greater curvature of the
stomach. Multiple small angioectasias with stigmata of recent bleeding were found in
the gastric body. No active bleeding or clear which angioectasia are bleeding source."
Multiple recently bleeding angioectasias in the stomach. Hemoglobin and hematocrit
low on admission and decreased following admission at 8.8 to 8.2 and 27.8 to 26.8
respectively. Patient transfused packed RBCs on 11/5/14.
Based on the above information , the review contractor:
a.Denied the DRG inappropriately
b.Was correct to deny the DRG, no query needed
