CDIP EXAM 1 LATEST 2024-2025 ACTUAL EXAM 50 QUESTIONS & CORRECT DETAILED ANSWERS, Exams of Health sciences

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CDIP EXAM 1 LATEST 2024-2025 ACTUAL EXAM 50

QUESTIONS & CORRECT DETAILED ANSWERS WITH

RATIONALES. ALREADY GRADED A+

A 68-year old nursing home patient with status post CVA 2 weeks ago presents via the ED with a 1-day history of fever, and elevated blood sugars in the 180- 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 - ANSC) Stage III Stage 1 ulcers have not yet broken through the skin. Stage 2 ulcers have a break in the top two layers of skin. Stage 3 ulcers affect the top two layers of skin, as well as fatty tissue. Stage 4 ulcers are deep wounds that may impact muscle, tendons, ligaments, and bone.

A CP patient was admitted with acute bronchitis, possible pneumonia. In reviewing the diagnoses below what additionally will impact the patient's ICD- code assignment? A) Spasticity B) Quadriplegia C) Both A and B D) None of the above - ANSC) Both A and B A patient 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 complication of liver transplant C) Query should not be performed as there are no liver complications D) No additional documentation needed for reporting - ANSA) Query should be performed for complication of liver transplant 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 bia 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 - ANSC) Gross hematuria A patient presented to the ED with a fever and WBCs at 25,000. The patient was experiencing fatigue and altered metal status and complaint of pain in the pelvic area. The patient also had elevated blood sugar of 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 D) No query warranted - ANSA) UTI being present on admission

A physician query may be appropriate in which of the following: A) Diagnosis of diastolic heart failure noted in the progress notes and echocardiogram showing systolic dysfunction with cardiomegaly B) Discharge summary indicates chronic pancreatitis but the progress notes document acute pancreatitis throughout the stay C) A colonic mass was removed via colonoscopy and sent to pathology. The diagnosis of malignant carcinoma of the colon mass when pathology state no malignancy D) All of the above - ANSD) All of the above A set of indicators providing information on potential in hospital complications and adverse events following surgeries, procedures, and childbirth: A) Core measures B) Healthcare Effectiveness Data and Information Set (HEDIS) C) Physician Quality Reporting System (PQRS) D) Patient Safety Indicators (PSI) - ANSD) Patient Safety Indicators (PSI) Abbreviations can be a source of patient safety issues due to misinterpretation and miscommunication. Abbreviations in the health record: A) Are not permitted by Joint Commission standards

B) Should have only one meaning C) Enhance patient safety D) Are critical to an electronic health record system - ANSB) Should have only one meaning Anywhere Hospital has been experiencing problems interacting with the medical staff. Anywhere should utilize which committee to assist these problems? A) Compliance committee B) Executive committee C) Medical staff committee D) Oversight committee - ANSD) Oversight committee 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 - ANSA) Appropriate The generation of a query should be considered when the health record documentation: Is conflicting, imprecise, incomplete, illegible, ambiguous, or inconsistent

Describes of is associated with clinical indicators without a definitive relationship to an underlying diagnosis Includes clinical indicators, diagnostic evaluation, and/or treatment not realted to a specific condition or procedure Provides a diagnosis without underlying clinical validation Is unclear for present on admission indicator assignment Dr. Smith is the physician advisor for a 200-bed hospital in the south. He has a very close relationship with the physicians within this small facility and they all share many of the patients. Dr Smith should: A) Tell the physicians he has the best relationships with the physicians and can tell them what to document B) Document specifically what is needed in the health record for the patient C) Not tell or ask a treating physician to document something specifically D) Respond to queries on patients they both have seen in the past 3 years - ANSC) Not tell or ask a treating physician to document something specifically Due to the compliance concerns surrounding the possible leading queries, CMA has engaged which organization to assist in record review of certain DRGs and documentation concerns

A) QIO

B) PEPPER

C) ONC

D) Q-Net - ANSA) QIO The QIO (Quality Improvement Organizations) Program, one of the largest federal programs dedicated to improving health quality for Medicare beneficiaries, is an integral part of the U.S. Department of Health and Human (HHS) Services' National Quality Strategy for providing better care and better health at lower cost. By law, the mission of the QIO Program is to improve the effectiveness, efficiency, economy, and quality of services delivered to Medicare beneficiaries. Based on this statutory charge, and CMS's program experience, CMS identifies the core functions of the QIO Program as: Improving quality of care for beneficiaries; Protecting the integrity of the Medicare Trust Fund by ensuring that Medicare pays only for services and goods that are reasonable and necessary and that are provided in the most appropriate setting; and Protecting beneficiaries by expeditiously addressing individual complaints, such as beneficiary complaints; provider-based notice appeals; violations of the Emergency Medical Treatment and Labor Act (EMTALA); and other related responsibilities as articulated in QIO-related law.

For accurate reporting and payment of hospital-acquired conditions, which of the following questions are important? A) Is there documented clinical evidence that the condition was present during the hospitalization? B) Is the condition present on admission? C) Was the condition present at the time of discharge? D) Both A and B - ANSD) Both A and B If a code does not agree with a code corresponding with the Medicare Code Edit table of acceptable codes, it is considered A) Duplicate B) Invalid C) Conflicting D) Unacceptable - ANSB) Invalid If a patient undergoes a biopsy immediately before the definitive surgery for a frozen section, how should this be coded with ICD-10_PCS codes? A) The approach to the definitive surgery B) Suture method C) Exploratory surgery

D) Open biopsy and definitive surgery - ANSD) Open biopsy and definitive surgery 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 - ANSC) APR-DRGs In assessing the quality of care given to a patient with diabetes mellitus, the CQI group collects data regarding blood sugar levels on admission and on discharge. This data is called: A) Indicator B) Measurement C) Assessment D) Outcome - ANSA) Indicator In project management, what is a work breakdown structure? A) A list of the project deliverables

B) A hierarchical list of the project tasks C) A document that defines team roles and responsibilities D) A list of project scope changes - ANSB) A hierarchical list of the project tasks Mechanical ventilation codes require consideration of: A) The time when a tracheal tube is inserted B) The replacement of an endotracheal tube C) The start time of endotracheal tube insertion followed by mechanical ventilation D) Mechanical ventilation during surgery - ANSC) The start time of endotracheal tube insertion followed by mechanical ventilation Modifier 59 provides guidance that a service is distinct and separate. Beginning January 2015, 4 new modifiers were created to provide greater reporting specificity in situations where modifier 59 was previously reported and may be utilized in lieu of modifier 59 whenever possible. These modifiers are: A) XA, XB, XC, XD B) CC44, CC45, CC46, CC C) XE, XS, XP, XU D) 44, 45, 46, 47 - ANSC) XE, XS, XP, XU

Queries should have a(n) _____ answer. A) Open-ended B) Yes or no C) Multiple-choice D) All of the above - ANSD) All of the above Severe sepsis with acute organ dysfunction requires a code for severe sepsis and: A) Specific organ dysfunction B) Underlying infection C) Sepsis only D) Multiple organ dysfunction - ANSB) Underlying infection Terms synonymous with query are clarification, clinical clarification, documentation alert, and ______? A) Inquiry B) Documentation clarification C) None, query is the only term D) Physician query - ANSB) Documentation clarification

The CDI manager at Star Hospital has been concerned aboput the hospital quality ratings over the past 2 years. She has been focused on educating physicians on documentation and working with CDS staff on hospital acquired conditions and MCC/CC capture.She may also want to educated regarding which area below to increase quality score: A) The principal diagnosis B) The principal procedure C) SOI D) None of the above - ANSC) SOI The CDS manager is implementing a process to review queries ongoing for format and appropriateness. This should be done: A) Weekly B) Monthly C) Quarterly D) Annually - ANSD) Annually The CDS review specialist has been performing CDI review on the first day of admission. What impact could this have on the review process?

A) None B) Provides the opportunity to capture POA diagnoses C) Can provide little positive impact due to clinical documentation is normally incomplete on the first day D) Gives the CDS the opportunity for the CDS to add the physician in building the documentation - ANSC) Can provide little positive impact due to clinical documentation is normally incomplete on the first day The codes for postoperative complications have been expanded and a distinction made between intraoperative complications and what? A) Other postop complications B) Postprocedural disorders C) Complications of trauma D) Intraoperative lacerations - ANSB) Postprocedural disorders The coding director has some concerns related to the capture of encephalopathy. She plans to take a closer look of coding, CDI, and code assignment. The director is performing a: A) A self-audit B) A self-review

C) A risk assessment D) Compliance review - ANSA) A self-audit The financial statement that presents a record of operations by showing revenue expenses over a period of time is called the: A) Income statement B) Balance sheet C) Statement of cashflows D) Statement of retained earnings - ANSA) Income statement The fiscal year 2016 Acute Patient Inpatient Prospective Payment System Final Rule Tables can be used by the CDI Specialist to determine the weight and estimated ______of each MS-DRG. A) Case mix B) Formula C) Quality D) Payment - ANSD) Payment The Glasgow Coma Scale includes evaluation of:

A) Eye opening response, verbal response, and motor response B) Visual response, verbal response, and motor response C) Eye opening response, verbal response, and neurological response D) None of the above - ANSA) Eye opening response, verbal response, and motor response The patient underwent laparotomy to determine if repair was needed to a patient's gastric bypass due to a fall later the day of procedure while in the hospital. No damage was identified and the would was closed. The CDS is not sure what root operation to use. The most appropriate root operation would be: A) Inspection B) Revision C) Exploration D) Repair - ANSA) Inspection The recovery auditor performed a review of 20 inpatient records. In review of the audit findings, it was determined the denials all had a common target. Review the denial summary below and determine what was targeted by the auditors: 186 MED

Pleural effusion w/MCC 190 MED COPD w/MCC 291 MED Heart failure and shock w/MCC 388 MED G.L. obstruction w/MCC A) Review of medical DRGs B) Review of LOS greater than 2 days C) Review of DRGs with MCC D) Both A and C - ANSD) Both A and C This document outlines areas of audit review as pursued by the Department of Health and Human Services by the Office of Inspector General (OIG) A) OIG Statement of Work B) OIG Final Rule

C) OIG Work Plan D) None of the above - ANSC) OIG Work Plan The OIG Work Plan outlines areas of audit and review as pursued by the Department of Health and Human Services by the Office of Inspector General (OIG). This document is published and updated yearly. This government audit agency calculates the national paid claims error rate for all of the Medicare fee-for-service claims paid by MACs A) Comprehensive Error Rate Testing (CERT) B) Recovery Audit Contractor (RAC) C) Medicare Administrative Contractor (MAC) D) No governmental agency regulates error rate - ANSA) Comprehensive Error Rate Testing (CERT) This root operation alters the diameter or route of a tubular body part and completely closes an orifice orlumen; for example, tubal ligation of Fallopian tubes: A) Dilation B) Ligation C) Occlusion

D) Restriction - ANSC) Occlusion This system is currently being used in EHR systems as a clinical reference terminology to capture data for problem lists and patient assessments at the point of care: A) Problem-oriented record B) CPT C) SNOMED-CT D) DSM-V - ANSC) SNOMED-CT To determine whether inpatient admission is reasonable and payable under Medicare Part A, this rule established a Medicare payment policy regarding the benchmark criteria of A) Utilization rule B) Short stay rule C) Two midnight rule D) 80/20 rule - ANSB) Short stay rule To ensure a CDI program is successful and sustainable it should have: A) Physician leadership

B) Metrics C) A CDI manager D) Resources such as CDI software - ANSA) Physician leadership Under CMS Program Integrity, one of the differences between a review and an audit is: A) Audits occur every 30 days B) Only contractors perform audits C) Audits are methodological in their approach D) There is no difference - ANSC) Audits are methodological in their approach What kind of data might be displayed on a pie chart? A) Average length of stay per year B) Percentage of discharges by third-party payer C) Number of discharges per year by third-party payer D) Number of patients discharged by sex and service - ANSB) Percentage of discharges by third-party payer A pie chart is an easily understood chart in which sizes of the pie show the proportional contribution of each part. Pie charts can be used to show the

component parts of a single group or variable and are intended for interval or ratio data. When a patient is admitted for treatment of a secondary malignancy with an active primary site the principle diagnosis should be: A) The primary malignancy B) The secondary malignancy C) Either condition D) Query should be performed - ANSB) The secondary malignancy When the documentation in the medical record is insufficient to assign a more specific code, a ___ code is assigned. A) MCC B) CC C) NOS D) Unspecified - ANSD) Unspecified When trying to determine if documentation is present to substantiate status asthmaticus, the coder should review the record for what terms and phrases? A) Intractable pneumonia

B) Refractory asthma and severe, intractable wheezing C) Airway obstruction relieved by bronchodilators D) Limited but pronounced wheezing - ANSB) Refractory asthma and severe, intractable wheezing Which of the following would generally be found in a query to a physician? A) Health record number and demographic information B) Name and contact number of the individual initiating the query and account number C) Date query initiated and date query must be completed D) Demographic information and name and contact number of individual initiating the query - ANSB) Name and contact number of the individual initiating the query and account number (A query generally includes: Patient name, admission date or DOS, health record number, account number, date query initiated, name and contact information of the individual initiating the query, and statement of the issue in the form of a question along with clinical indicators specified from the chart)