CDIP Domain 1: Clinical Coding Practice,
Questions & Answers, 100% Accurate,
Graded A
Coding Clinic - ✔✔-Valuable reference tool for coders that is published by AHA each quarter
CPT - ✔✔-Current Procedural Terminol
...
CDIP Domain 1: Clinical Coding Practice,
Questions & Answers, 100% Accurate,
Graded A
Coding Clinic - ✔✔-Valuable reference tool for coders that is published by AHA each quarter
CPT - ✔✔-Current Procedural Terminology
MS-DRGs - ✔✔-Medicare Severity-Diagnosis Related Groups
CPT Assistant - ✔✔-Monthly publication by the AMA that provides coding advice for CPT coding
scenarios
Encoder Nosology - ✔✔-Provides coding professionals from the encoder company that are available to
help answer tough coding questions
History & Physical - ✔✔-Provides the initial chief complaint and initial impressions of the provider when
the patient is first admitted. It also has a comprehensive physical review of the patient's body systems
and vital signs, and provides the initial treatment plan, medications, and tests that are being ordered to
treat the patient.
Progress Notes - ✔✔-Provide information about what is going on with the patient on a day-to-day basis;
they should include the diagnoses that are being treated as well as any information about any changes
in the patient's well-being and tests/procedures being performed.
Operative and Pathology Reports - ✔✔-Summarize the invasive procedures performed and any samples
that are removed from the patient's body
Pathology report - ✔✔-Provides detailed information from the pathologist of the facility as to the status
of the tissues or organs removed from the patient's body
Encoder - ✔✔-Specialty software used to facilitate the assignment of diagnostic and procedural codes
according to the rules of the coding system
What is the value of utilizing coding software? - ✔✔-It facilitates accurate coding by providing links to
coding resources, groups diagnosis and procedure codes to the correct MS-DRG, and provides edits with
additional information for the coder to consider when placing codes into the encoder
Principal diagnosis - ✔✔-Diagnosis that, after study, is the reason for the patient's admission to the
hospital.
Secondary diagnoses - ✔✔-Additional supporting information for the conditions the patient is being
cared for
MCC - ✔✔-Major Complication or Comorbidity
CC - ✔✔-Complication or Comorbidity
CMI - ✔✔-Case Mix Index
LOS - ✔✔-Length of Stay
Complication - ✔✔-A condition arising during the hospital stay that prolongs the LOS by at least one day
in approximately 75% of the cases
Comorbidity - ✔✔-A pre-existing condition which because of its presence with the principal diagnosis
will increase the LOS by at least one day in 75% of the cases
Primary procedures - ✔✔-Procedure codes that best represent the procedure that has been performed
Secondary procedures - ✔✔-Do not typically impact the MS-DRG; however, they are important for
capturing the details of the care the patient has received while in the hospital.
Coding conventions for ICD-10-CM - ✔✔-General rules for the use of the classification independent of
the guidelines
Letter that ICD-10 utilizes as a placeholder for certain codes - ✔✔-X
Excludes1 - ✔✔-Indicates that the code excluded should never be used with the code above the
Excludes1 note.
Excludes2 - ✔✔-Indicates that, when appropriate, it is acceptable to use both the code and the excluded
code together.
Inclusion terms - ✔✔-List of terms that are included under some codes. They are the conditions for
which the code should be used.
CMS - ✔✔-Centers for Medicare & Medicaid Services
Medicare patients are reimbursed by - ✔✔-MS-DRGs
Medicaid has it's rates set by - ✔✔-each individual state
PPS - ✔✔-Prospective Payment System
Prospective Payment System - ✔✔-Payment method based on a predetermined amount that results
from a particular service
APR-DRG - ✔✔-All Patient Refined Diagnosis Related Groups
All Patient Refined DRGs - ✔✔-Incorporate severity of illness as a part of assigning DRGs to determine
the complexity of the patient and the need for an increased utilization of resources as the patient moves
to a higher level of severity of illness based on additional diagnoses.
APG - ✔✔-Ambulatory Pati
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