CDIP Practice Exam 2 with 100% Correct Answers 2023 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 answerIf 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 ICD10-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: