CDIP Practice Exam 2 Top Questions and answers, 100% Accurate. Graded A+

CDIP Practice Exam 2 Top Questions and answers, 100% Accurate. Graded A+ A physician admits a patient with shortness of breath and chest pain, then treats the patient with Lasix, oxygen, and Theophylline. The physic ...

CDIP Practice Exam 2 Top Questions and answers, 100% Accurate. Graded A+ 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 - ✔✔- 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 - ✔✔-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 - ✔✔-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 - ✔✔-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 - ✔✔-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 - ✔✔-b The APR-DRG system is distributed into levels (subclasses) similar to MSDRGs. 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 - ✔✔-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 - ✔✔-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 - ✔✔-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) - ✔✔-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 - ✔✔-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: a.Ruptured appendix b.Exploratory laparoscopy c.Abdominal pain d.Cholelithiasis - ✔✔-c 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 - ✔✔-c 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 - ✔✔-a 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 - ✔✔-b 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. a.CPT b.ICD-10-PCS c.ICD-10 CM d.POA - ✔✔-a Level I of HCPCS is composed of the CPT codes as published by the AMA and represents medical services and procedures performed by physicians and other healthcare providers. The Level I (CPT) codes (other than the Category II and III codes) are five-digit numeric codes (Palkie 2013, 394). A patient has a prostate malignancy that had not been excised, removed, and still under treatment. The patient presents to the hospital with irregular heartbeat, malaise and gross hematuria with large amounts of blood being passed via the urethra with the inability to urinate. Patient was noted to have a hemoglobin of 10.8 due to significant blood loss, the patient was transfused and bladder irrigation was begun. Following significant irrigation, urine ran clear. Based on the above scenario, what is the principal diagnosis? a.Blood loss b.Prostate malignancy c.Gross hematuria d.Query warranted to determine the principal - ✔✔-c The diagnosis of gross hematuria should be selected as principal as the treatment was not directed toward the malignancy and the rule of assignment of the principal diagnosis would apply to this circumstance (AHA Second Quarter 2010). Based on the diagnosis of gross hematuria, signs and symptoms of irregular heartbeat, malaise, and hemoglobin of 10.8 with transfusion, query for anemia due to blood loss may be______: a.Appropriate b.Inappropriate - ✔✔-a The generation of a query should be considered when the health record documentation: •Is conflicting, imprecise, incomplete, illegible, ambiguous, or inconsistent •Describes or is associated with clinical indicators without a definitive relationship to an underlying diagnosis •Includes clinical indicators, diagnostic evaluation, and/or treatment not related to a specific condition or procedure •Provides a diagnosis without underlying clinical validation •Is unclear for present on admission indicator assignment The _________ diagnosis is designated and defined as the condition established after study to be chiefly responsible for occasioning the admission of the patient to the hospital a.Secondary b.DRG diagnosis c.Most resource intensive d.Principal - ✔✔-d The Principal diagnosis should be assigned as the first-listed diagnosis for the hospital admission as the cause of the hospital stay after study and evaluation by the responsible physician (ICD10-CM Official Coding Guidelines 2016b, 88). A patient was admitted for ruptured appendix and an emergent appendectomy was performed. Abscess was noted on visual exam. During the admission, the patient had an MI and a stent was placed. What sequencing order should the procedures be placed in and which should be principal? a.The stent placement is more severe and should be first listed b.The appendectomy is considered incidental c.The appendectomy should be first listed d.Either can be assigned as the principal procedure - ✔✔-c When two definitive procedures have been performed, the for sequencing should be based on the procedure most related to the principal diagnosis as the first procedure to be listed (AHA Fourth Quarter 2012, 80). A patient presents with a myocardial infarction (MI) and intervention was carried out. It was noted the patient does have coronary artery disease (CAD). The consulting physician has stated to staff the CAD should be sequenced first. What should be the principal diagnosis? a.CAD b.MI c.Chest pain d.Ill-defined condition - ✔✔-b No, the consultant's advice is not correct. Sequence the AMI as the principal diagnosis since it is the acute condition and the reason for the admission. You should continue to follow correct coding and reporting practices and report the AMI as the principal diagnosis (AHA Third Quarter 2009, 9-10. AHA, First Quarter 2012, 7). At times, patients present to the hospital with hematoma. There is noted midline shift of mass effect. Based on the diagnosis, signs or symptoms, and treatment: a.The CDS could consider mass effect query b.The CDS could consider cerebral blood clot query c.The CDS could consider brain compression query d.The CDS could have no considerations - ✔✔-c The coder should query the provider and if the provider clarifies and documents that the mass effect or midline shift is brain compression, the coder may then assign a code for the brain compression (AHA 2011, 11). If a patient is given Levophed, the patient is most likely being treated for which of the following diagnoses? a.Shock b.Infection c.Hemorrhage d.Infarction - ✔✔-a This is a treatment for shock (septic and cardiogenic). (Society of Critical Care Medicine 2013) A 68-year-old nursing home patient with status post CVA 2 weeks ago presents via the emergency department with a 1-day history of fever, and elevated blood sugars in the 180-210 range. The patient has stated they have significant pain of the right buttock since the previous admission. The patient has a history of diabetes, and is on long-term insulin. On physical exam, it is noted the patient had a fever of 101.3 with purulent drainage with exposure of subcutaneous fat. This type of ulcer can be called a: a.Stage I b.Stage II c.Stage III d.Stage IV - ✔✔-c This is a Stage III ulcer; Full thickness skin loss. The National Pressure Ulcer Advisory Panel (NPUAP) has redefined the definition of a pressure ulcer and the stages of pressure ulcers. (AHA Fourth Quarter 2008, 132) This catheter is inserted into larger, deeper veins such as the subclavian, jugular, or femoral veins. The catheter is then advanced into the superior vena cava leading directly to the heart. a.Peripherally inserted central catheter (PICC) b.Vascular access device (VAD) c.Central venous catheter d.None of the above - ✔✔-c Central venous catheters are inserted into larger, deeper veins such as the subclavian, jugular, or femoral veins. The catheter is then advanced into the superior vena cava leading directly to the heart. Central venous catheters may be inserted by physicians, but are often inserted by other specially trained personnel such as physician assistants, nurse practitioners, or critical care nurses. Central venous catheterization is usually performed in the subclavian vein by a subclavicular approach. Another site is the internal jugular vein. The femoral vein is used infrequently because of concern over deep vein thrombosis (DVT) (AHA First Quarter 1996, 3-4). Within 2 hours following surgery, a 68 year-old female began to develop noisy breathing, fever, tachypnea, chest discomfort, and cough. Chest x-ray was performed which showed increased interstitial markings, lobar consolidation, and atelectasis. The physician documented pneumonia; concern for aspiration. The patient was started on Cefepime. The CDS would most likely query for: a.Postoperative aspiration pneumonia b.Respiratory failure c.Bacterial pneumonia d.No query needed - ✔✔-a Postprocedural aspiration pneumonia was developed to uniquely capture this condition and distinguish it from other respiratory complications Query as appropriate utilizing appropriate query format. (AHIMA 2013b). Patient is admitted with acute congestive heart failure treated with diuretics and education. The patient also had atrial fibrillation which the physician stated as the cause of the heart failure. Which condition should be assigned as principal? a.Coding rules state query should be performed b.The condition documented as causing the admission c.Either diagnosis d.Neither - ✔✔-b If both conditions are present on admission and meet the definition of principal diagnosis, either condition may be sequenced as principa