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.CDIP Practice Exam 2 | 119 Questions
and Answers 100% Correct
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 - 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 - 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 - 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 - 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 - Answer a If a patient is admitted for an HIVrelated 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 - 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
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