CDIP EXAM 2 LATEST 2023-2024 ACTUAL EXAM
130 QUESTIONS AND CORRECT DETAILED
ANSWERS WITH RATIONALES||ALREADY
GRADED A+
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 RATIONALE: 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 RATIONALE: 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 (ICD10-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 RATIONALE: 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 RATIONALE: 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 RATIONALE: 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 RATIONALE: 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 RATIONALE: 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 – ANSWER- c RATIONALE: 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
c.Should not have denied the DRG
d.Was correct to deny, query needed – ANSWER- a RATIONALE: The
assignment of the code is appropriate. If the physician clearly documents the
anemia is due to acute blood loss, code D62 Acute posthemorrhagic anemia should
be assigned. Anemia due to chronic blood loss is coded to D50.0 Secondary to
blood loss (chronic). The physician should always be queried if there is a lack of
sufficient documentation. Never assume cause and effect relationship (AHA
Fourth Quarter 1993, 34; ICD-10-CM Official Guidelines 2016b).
This is a communication tool used to clarify documentation in the health record for
accurate code assignment.
a.Attestation
b.Query
c.Health record inquiry
d.Additional documentation request – ANSWER- b RATIONALE: A query is a
communication tool used to clarify documentation in the health record for accurate
code assignment. This tool is usually generated by coding and CDI staff (AHIMA
2013b, 1).
What coding system is published by the AMA and represents medical services and
procedures performed by physicians and other healthcare providers.
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