CDIP Practice Exam LATEST VERSION 2023
2024 GRADED A+
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 - Ans c 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 32-year-old female fractured her ankle when she stumbled over the shopping cart while pushing it in the supermarket. The orthopedic surgeon recommended open fusion of the right ankle with direct internal fixation, which was performed. Complete the coding of this procedure using the chart below
OSGF _ _ _
ApproachDeviceQualifier0 Open4 Internal Fixation DeviceZ No Qualifier3 Percutaneous5 External Fixation Device4 Percutaneous endoscopic7 Autologous Tissues SubstituteJ Synthetic SubstituteK Nonautologous Tissues SubstituteZ No device a.OSGF34Z b.OSGF05Z c.OSGF04Z d.OSGF35Z - Ans c The correct code assignment for Fusion of the right ankle open with internal fixation is OSGF04Z (Leon-Chisen 2013, 102).
A 32-year-old female had a liver transplant 2 years ago. She has been experiencing problems with her kidneys with a GFR of 20 and Stage IV CKD. She is noted to have
some jaundice. Based on this:
a.Query should be performed for complication of liver transplant b.Query should be performed for rejection of liver transplant c.Query should not be performed as there are no liver complications d.No additional documentation needed for reporting - Ans a It is noted that the patient has a previous liver transplant and experiencing jaundice. If a transplant complication such as failure or rejection or other transplant complication is documented, see section I.C. 19.g for information on coding complications of a kidney transplant. If the documentation is unclear as to whether the patient has a complication of the transplant, query the provider (ICD-10-CM Official Guidelines for Coding and Reporting 2016b, 52).
A 60-year-old female was admitted with hip fracture and replacement was planned. On day three of admission it was noted that the congestive heart failure (CHF) with shortness of breath and 3+ pedal edema. The patient was started on IV Lasix at 40 mg.The physician states admission for CHF and fracture of hip on the discharge summary. 1 / 4
The CDS performed a query stating-Patient treated with 40 mg Lasix. Please document Acute CHF.This query is a.Non-leading and appropriate b.Leading and inappropriate - Ans b This query is leading in asking the physician specifically what to document. A leading query is one that is not supported by the clinical elements in the health record or directs a provider to a specific diagnosis or procedure (AHIMA 2013b, 50-53).
A 65-year-old male was admitted with GI (gastrointestinal) bleed and was administered
- units of packed red blood cells. The physician documented acute GI bleed. The CDS
performed a query stating, 'Patient noted to have acute GI bleed treated with transfusion." Is this blood loss anemia?This query is a.Non-leading and appropriate b.Leading and inappropriate - Ans b This query is leading in asking the physician specifically what to document. A leading query is one that is not supported by the clinical elements in the health record or directs a provider to a specific diagnosis or procedure (AHIMA 2013b, 50-53).
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 - Ans c ICD-10 includes the site of the of the hemorrhage for increased specificity.
A CDI program should allow concurrent documentation review to:
a.educate clinical care providers b.allow providers to clarify hospital acquired conditions and present on admission indicators c.address areas of quality impact d.all of the above - Ans d Queries should address areas of quality impact such as present on admission indicators and hospital acquired conditions (Hess 2015, 234).
A CDI program should have a.Training b.Physician advisor or champion c.Nurses or coders performing CDI review d.None of the above - Ans b A physician advisor/champion should be officially designated as the physician leader for CDI (Hess 2015, 122).
A coder notes that the patient is taking prescribed Haldol. The final diagnoses on the progress notes include diabetes mellitus, acute pharyngitis, and malnutrition. What 2 / 4
condition might the coder suspect the patient has that the physician should be queried to confirm?a.Insomnia b.Hypertension c.Mental or behavioral problems d.Rheumatoid arthritis - Ans c Haldol is a drug frequently administered for behavior or mental conditions, so the coder would suspect mental or behavioral problems for this patient. The physician must be queried to confirm the diagnosis. Documentation is needed in the record to support the coding of the mental or behavioral problem (Shaw and Carter 2014; Schraffenberger and Kuehn 2011, 285).
A compliant CDI program should have components to include a.Documented, mandatory physician education b.Detailed query documentation c.CDI policies and procedures with annual sign-off from all program staff d.All of the above - Ans d A compliant CDI program should have components to include documented, mandatory physician education as they are ultimately responsible for the documentation, detailed query documentation for compliance, and CDI policies and procedures with annual sign-off from all program staff to ensure correct messaging of information (Hess 2015, 208).
A facility has a MSDRG utilization rate of 85% of MCCs for a specific MSDRG. This
could indicate:
a.underutilization b.overutilization c.a compliance risk d.both Band C - Ans d A higher utilization of a specific DRG in comparison to peers could indicate a documentation/coding issue (Hess 2015, 90).
A new CDI program is experiencing conflicts within the health record between a consulting physician and the physician ultimately responsible for the documentation of
the patient. The physician ultimately responsible is the:
a.Consulting physician b.Hospitalist c.Attending physician d.Intensivist - Ans c The attending physicians are responsible for the documentation that supports the final diagnostic statement for the patient (42 CFR 412.46). The attending physician should be asked to provide the final documented response when inconsistencies arise within the record (42 CFR 412.46; Hess 2015, 29).
A new nursing or HIM graduate may not be the right candidate for a CDI position at a
large quaternary care center due to:
a.Lack of basic coding knowledge b.Lack of experience with clinical concepts c.Both a and b 3 / 4
d.None of the above - Ans c The CDI specialists should have a clinical or health information background with record review experience. They should be able to effectively communicate with physicians and skillfully review clinical documentation to determine where it fails to meet the criteria for high quality (Hess 2015, 129).
A new or restructuring CDI program should ask:
a.How can the bottom line be increased?b.How many queries must be performed for financial success?c.Why does clinical documentation need to be improved?d.How fast can this be done? - Ans c Understanding why a facility want to improve clinical documentation to support the vision of the program for all involved in the effort (Hess 2015, 205).
A patient has a stage III pressure ulcer noted in the ED. While the patient is in the hospital for 6 days, the ulcer progresses to stage IV. The correct POA assignment
would be:
a.Y-yes b.N-no c.U-unknown d.None of the above - Ans a The pressure ulcer was noted on admission. Assign "Y" for conditions diagnosed during the admission that were clearly present but not diagnosed until after admission occurred (ICD-10-CM Official Guidelines for Coding and Reporting 2016b, 109).
A patient is being seen in the clinic for possible CHF. She has pedal edema and shortness of breath. The physician's office note states rule out, CHF; shortness of
breath. The patient's reported diagnosis for this outpatient visit should be:
a.CHF b.Rule out CHF c.Shortness of breath d.Shortness of breath and pedal edema - Ans d The shortness of breath and pedal edema would be reported for this outpatient visit. Do not code diagnoses documented as "probable," "suspected," "questionable," "rule out," or "working diagnosis" or other similar terms indicating uncertainty. Rather, code the condition(s) to the highest degree of certainty for that encounter/visit, such as symptoms, signs, abnormal test results, or other reason for the visit (ICD-10-CM Official Guidelines for Coding and Reporting 2016b, 104).
A patient presented to the ED with a fever and WBCs at 25,000. The patient was experiencing fatigue and altered mental status and complaint of pain in the pelvic area.The patient also had elevated blood sugar at 286, was thought to be in ketoacidosis, and was subsequently admitted. The physician documented catheter-associated UTI at discharge. Based on the physician documentation, the CDS may want to query for a.UTI being present on admission b.Type of organism c.Uncontrolled diabetes
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