CDIP EXAM 1 LATEST 2023-2024 ACTUAL EXAM
130 QUESTIONS AND CORRECT DETAILED
ANSWERS WITH RATIONALES||ALREADY
GRADED A+
When trying to determine if documentation is present to substantiate status
asthmaticus, the coder should review the record for what terms and phrases?
a.Intractable pneumonia
b.Refractory asthma and severe, intractable wheezing
c.Airway obstruction relieved by bronchodilators
d.Limited but pronounced wheezing – ANSWER- b RATIONALE: Status
asthmaticus is defined as continual wheezing in spite of therapy (Leon-Chisen
2013, 230).
Gastrointestinal bleeding can manifest as:
a.Hematemesis, which indicates acute upper gastrointestinal hemorrhage
b.Petechia
c.Vomiting
d.Constipation, which indicates upper or lower gastrointestinal hemorrhage –
ANSWER- a RATIONALE: Gastrointestinal bleeding manifests itself in several
ways. These are hematemesis, melena, occult bleeding, hematochezia (LeonChisen 2013, 244).
Which types of pacemaker devices have a unique ICD-10-PCS code.
a.Dual chamber rate responsive
b.Single chamber, single chamber rate responsive, and dual chamber
c.Multiple chamber
d.Multiple chamber rate responsive – ANSWER- b RATIONALE: The three types
of pacemakers are single chamber, single chamber rate responsive, and dual
chamber. A single chamber uses a single lead; a dual chamber requires two leads,
one in the atrium and one in the ventricle. The leads should also be coded (LeonChisen 2013, 416-418).
Mechanical ventilation codes require consideration of which of the following?
a.The time when a tracheal tube is inserted
b.The replacement of an endotracheal tube
c.The start time of endotracheal tube insertion followed by mechanical ventilation
d.Mechanical ventilation during surgery – ANSWER- c RATIONALE: Codes for
mechanical ventilation indicate whether the patient was on mechanical ventilation
for less than 24 hours, 24-96 consecutive hours and greater than 96 consecutive
hours. The start time for calculating the duration begins with the start time of
endotracheal tube insertion as the best method, followed by mechanical ventilation
or the time that a patient who is on mechanical ventilation is admitted. The time
ends with discontinuance of mechanical ventilation (Leon-Chisen 2013, 239-240).
Abbreviations can be a source of patient safety issues due to misinterpretation and
miscommunication. Abbreviations in the health record:
a.Are not permitted by Joint Commission standards
b.Should have only one meaning
c.Enhance patient safety
d.Are critical to an electronic health record system – ANSWER- b RATIONALE:
The Joint Commission has established a cautious quality approach to the use of
abbreviations in all its accredited organizations. To comply, every healthcare
organization should strive to limit or eliminate the use of abbreviations by
developing an organizationspecific abbreviation list so that only those
abbreviations approved by the organization are used. When more than one
meaning for an approved abbreviation exists, an organization should choose only
one meaning or context in which the abbreviation is to be used (Shaw and Carter
2014; Brodnik et al. 2012, 180-181).
In ICD-10-PCS, what value is used if there is a character that does not apply to a
given code?
a.X
b.Z
c.0
d.- – ANSWER- b RATIONALE: All ICD-10-PCS codes must be seven
characters, and a character cannot be left blank. If a value does not exist for a given
character, the Z is used as the value (Shaw and Carter 2014; Kuehn and Jorwic
2013, 5).
Which symbol of punctuation is used in the Tabular List to enclose synonyms,
alternative wording, or explanatory phrases?
a.Parentheses
b.Brackets
c.Colon
d.Comma – ANSWER- a RATIONALE: Punctuation is widely used in coding.
Brackets are used in the Alphabetic Index to identify manifestation codes as well
as to enclose synonyms, alternative wording or explanatory phrases. (ICD-10-CM
Official Guidelines for Coding and Reporting 2016b, 8)
When the documentation in the medical record is insufficient to assign a more
specific code, a _ code is assigned.
a.MCC
b.CC
c.NOS
d.Unspecified – ANSWER- d RATIONALE: When documentation in the record is
not available to assign a more specific code, an unspecified code is assigned (ICD10-CM Official Guidelines for Coding and Reporting 2016b, 10)
A 30-year-old cerebral palsy patient was admitted with acute bronchitis, possible
pneumonia. In reviewing the diagnoses below what additionally will impact the
patient’s ICD-10 code assignment.
a.Spasticity
b.Quadriplegia
c.Both A and B
d.None of the above – ANSWER- c RATIONALE: ICD-10 Cerebral palsy and
other paralytic syndromes (G80-G83) has additional specificity for spasticity as
well as state of paralysis if any (AHIMA 2015, 23).
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 additionally could
impact code assignment for the embolism code?
a.Hematemesis
b.Hypertension
c.Site of the hemorrhage
d.Seizure – ANSWER- c RATIONALE: ICD-10 includes the site of the of the
hemorrhage for increased specificity.
If a patient undergoes a biopsy immediately before the definitive surgery for a
frozen section, how should this be coded with ICD-10-PCS codes?
a.The approach to the definitive surgery
b.Suture method
c.Exploratory surgery
d.Open biopsy and definitive surgery – ANSWER- d The open biopsy is performed
prior to the definitive surgery so that the pathologist can perform a frozen section
of the tissue to determine malignancy. Approaches, suturing, and closure are not
coded separately. Exploratory surgery is not coded when definitive surgery is
performed (Leon-Chisen 2013, 92).
A patient was admitted with diminished responsiveness and hypotension. The
patient has a history of hypertension, CVA, CHF, and asthma. The patient suffered
a cardiac arrest immediately following admission. The documentation within the
record should:
a.List hypotension as first-listed
b.Include the reason for the cardiac arrest
c.Include the date of the previous CVA
d.Type of hypotension – ANSWER- b RATIONALE: Instructional notes in ICD10-CM for cardiac arrest states “code first underlying condition”.
Causes of nonpressure ulcers of the lower limb include:
a.Varicose ulcers
b.Chronic venous hypertension
c.Diabetic ulcer
d.All of the above – ANSWER- d RATIONALE: The causes of lower limb ulcers
include Atherosclerosis of lower extremity, Chronic venous hypertension, Diabetic
ulcer, Postphlebitic syndrome, Postthrombotic syndrome, Varicose ulcer, and
Other as specified (AHIMA 2015, 38).
An 82-year-old female was walking and inadvertently twisted an ankle causing a
minor fall. The patient suffered a fracture of the tibia. The patient was treated and
released. It was discussed with the patient to take her hydrocodone as prescribed
and continue her medications for osteoporosis, hypertension, and calcium. This
fracture:
a.is only a minor setback for the patient
b.has Core measures to meet for quality
c.is coded as pathologic with osteoporosis
d.is coded as a traumatic fracture – ANSWER- c RATIONALE: Osteoporosis
with current pathological fracture: A code from category M80, not a traumatic
fracture code, should be used for any patient with known osteoporosis who suffers
a fracture, even if the patient had a minor fall or trauma, if that fall or trauma
would not usually break a normal, healthy bone (ICD-10-CM Official Guidelines
for Coding and Reporting 2016b, 51).
A patient presented with pain in the right foot; right big toe. On physical exam, the
toe was noted to be red and warm to touch. Laboratory findings show an elevated