AHIMA CDIP Online Practice Questions and Exam Preparation

AHIMA CDIP Online Questions & Answers

• Question 31:

  A patient is admitted for pneumonia with a WBC of 20,000, respiratory rate 20, heart rate 85, and oral temperature 99.0? On day 2, sputum cultures reveal positive results for pseudomonas bacteria. The most appropriate action is to

  A. code pneumonia, unspecified
  B. query the provider to see if pseudomonas sepsis is supported by the health record
  C. query the provider to document the etiology of pneumonia
  D. code pseudomonas pneumonia
  C. query the provider to document the etiology of pneumonia

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  Explanation/Reference:

  The most appropriate action in this case is to query the provider to document the etiology of pneumonia, which is pseudomonas bacteria. This is because the etiology of pneumonia affects the coding and classification of the condition, as well as the severity of illness, risk of mortality, and reimbursement. According to the ICD-10-CM Official Guidelines for Coding and Reporting, pneumonia should be coded by type whenever possible, and if the type of pneumonia is not documented, then the default code is J18.9, Pneumonia, unspecified organism 2. However, if the type of pneumonia is documented, then a more specific code can be assigned, such as J15.1, Pneumonia due to Pseudomonas 3. Therefore, querying the provider to document the etiology of pneumonia will improve the accuracy and completeness of the documentation and coding, and reflect the true clinical picture of the patient. References: 1: AHIMA CDIP Exam Prep, Fourth Edition, p. 139 4 2: ICD-10-CM Official Guidelines for Coding and Reporting FY 2021, Section I.C.9.a 3: ICD-10-CM Code J15.1 - Pneumonia due to Pseudomonas

• Question 32:

  A 27-year-old male patient presents to the emergency room with crampy, right lower quadrant abdominal pain, a low-grade fever (101?Fahrenheit) and vomiting. The patient also has a history of type I diabetes mellitus. A complete blood count reveals mild leukocytosis (13,000/microliter). Abdominal ultrasound is ordered, and the patient is admitted for laparoscopic surgery. The patient is given an injection of neutral protamine Hagedorn insulin, in order to normalize the blood sugar level prior to surgery. Upon discharge, the attending physician documents "right lower quadrant abdominal pain due to possible acute appendicitis or probable Meckel diverticulitis".

  What is the proper sequencing of the principal and secondary diagnoses?

  A. Right lower quadrant abdominal pain, acute appendicitis, Meckel diverticulitis, fever, vomiting, leukocytosis
  B. Right lower quadrant abdominal pain, fever, vomiting, leukocytosis
  C. Acute appendicitis, Meckel diverticulitis, type I diabetes mellitus
  D. Acute appendicitis, right lower quadrant abdominal pain, type I diabetes mellitus
  D. Acute appendicitis, right lower quadrant abdominal pain, type I diabetes mellitus

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  Explanation/Reference:

  The proper sequencing of the principal and secondary diagnoses in this case is as follows: Principal diagnosis: Acute appendicitis. This is the condition, after study, that occasioned the admission to the hospital, according to the ICD-10-CM Official Guidelines for Coding and Reporting. The patient was admitted for laparoscopic surgery, which is a definitive treatment for acute appendicitis. The physician documented "possible acute appendicitis or probable Meckel diverticulitis" as the cause of the right lower quadrant abdominal pain. According to the AHA's Coding Clinic, Fourth Quarter 2016, pp. 147-148, when a physician documents two diagnoses connected by "or", coders should query the physician for clarification if possible. However, if a query is not possible or not answered, coders should assign codes for both conditions, unless one of them has been ruled out or confirmed by further testing or treatment. In this case, there is no indication that either acute appendicitis or Meckel diverticulitis has been ruled out or confirmed by further testing or treatment. Therefore, both conditions should be coded and reported. However, only one of them can be the principal diagnosis. Since acute appendicitis is more commonly associated with laparoscopic surgery than Meckel diverticulitis, and since it has a higher relative weight than Meckel diverticulitis under the MS-DRG system, it is reasonable to select acute appendicitis as the principal diagnosis 23. Secondary diagnosis: Right lower quadrant abdominal pain. This is a sign or symptom that is associated with the principal diagnosis and requires clinical evaluation, therapeutic treatment, diagnostic procedures, extended length of hospital stay, or increased nursing care and/or monitoring. The patient presented with right lower quadrant abdominal pain as a manifestation of acute appendicitis or Meckel diverticulitis. The pain required clinical evaluation by abdominal ultrasound and therapeutic treatment by laparoscopic surgery. Therefore, it should be coded and reported as a secondary diagnosis 4. Secondary diagnosis: Type I diabetes mellitus. This is a chronic condition that affects the patient's care in terms of requiring diagnostic or therapeutic services or affecting patient outcomes or resource utilization. The patient has a history of type I diabetes mellitus and received an injection of neutral protamine Hagedorn insulin to normalize the blood sugar level prior to surgery. Therefore, it should be coded and reported as a secondary diagnosis 4. References: 1: AHIMA CDIP Exam Prep, Fourth Edition, p. 133 2: ICD-10-CM Official Guidelines for Coding and Reporting FY 2021, Section II.A 3: AHA Coding Clinic for ICD- 10-CM and ICD-10-PCS, Fourth Quarter 2016 4: ICD-10-CM Official Guidelines for Coding and Reporting FY 2021, Section III.C : AHIMA CDIP Exam Prep, Fourth Edition https://my.ahima.org/store/product?id=67077

• Question 33:

  When a change in departmental workflow is necessary, the first step is to

  A. define the gaps and solutions
  B. set realistic timelines
  C. re-engineer the process
  D. assess the current workflow
  D. assess the current workflow

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  Explanation/Reference:

  The first step in changing a departmental workflow is to assess the current workflow and identify the problems or inefficiencies that need to be addressed. This will help to define the gaps and solutions, set realistic timelines, and re-engineer the process. References: AHIMA. "CDIP Exam Preparation." AHIMA Press, Chicago, IL, 2017: 125- 126.

• Question 34:

  The physician advisor/champion needs to provide ongoing education regarding coding and reimbursement regulations to the A. clinical documentation integrity staff

  B. organization senior administration staff
  C. Health Information Management coding staff
  D. organization's medical and surgical staff
  D. organization's medical and surgical staff

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  Explanation/Reference:

  The physician advisor/champion is a key role in the CDI program who serves as a liaison between the CDI staff and the organization's medical and surgical staff. The physician advisor/champion needs to provide ongoing education regarding coding and reimbursement regulations to the organization's medical and surgical staff to promote awareness, understanding, and compliance with CDI initiatives and goals. References: AHIMA. "CDIP Exam Preparation." AHIMA Press, Chicago, IL, 2017: 97-98.

• Question 35:

  Which of the following is the definition of an Excludes 2 note in ICD-10-CM?

  A. Neither of the codes can be assigned
  B. Two codes can be used together to completely describe the condition
  C. Only one code can be assigned to completely describe the condition
  D. This is not a convention found in ICD-10-CM
  B. Two codes can be used together to completely describe the condition

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  Explanation/Reference:

  An Excludes 2 note in ICD-10-CM indicates that the condition excluded is not part of the condition represented by the code, but a patient may have both conditions at the same time. When an Excludes 2 note appears under a code, it is

  acceptable to use both the code and the excluded code together to completely describe the condition. For example, under code R05 Cough, there is an Excludes 2 note for whooping cough (A37.-). This means that a patient can have both a

  cough and whooping cough at the same time, and both codes can be used together to capture the full clinical picture.

  References:

  CDIP?Exam Content Outline (https://www.ahima.org/media/1z0x0x1a/cdip-exam- content-outline.pdf)

  ICD-10-CM Features | Diagnosis Coding: Using the ICD-10-CM1

• Question 36:

  An 80-year-old male is admitted as an inpatient to the ICU with shortness of breath, productive yellow sputum, and a temperature of 101.2. CXR reveals bilateral pleural effusion and LLL pneumonia. Labs reveal a BUN of 42 and a creatinine level of 1.500.

  The patient is given Zithromax 500 mg. IV, NS IV, and Lasix 40 mg tabs 2x/day. The attending physician documents bilateral pleural effusion, LLL pneumonia, and kidney failure. Two days later, the renal consult documents AKI with acute tubular necrosis (ATN). The correct principal and secondary diagnoses are

  A. PDx: AKI with ATN SDx: LLL pneumonia, bilateral pleural effusion
  B. PDx: LLL pneumonia SDx: Bilateral pleural effusion, kidney failure
  C. PDx: LLL pneumonia SDx: AKI with ATN, bilateral pleural effusion
  D. PDx: Bilateral pleural effusion SDx: LLL pneumonia, kidney failure
  C. PDx: LLL pneumonia SDx: AKI with ATN, bilateral pleural effusion

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  Explanation/Reference:

  According to the ICD-10-CM Official Guidelines for Coding and Reporting FY 2023, the principal diagnosis is defined as "the condition established after study to be chiefly responsible for occasioning the admission of the patient to the hospital for care"2. In this case, the patient was admitted with shortness of breath, productive yellow sputum, and a temperature of 101.2, which are signs and symptoms of pneumonia. The CXR confirmed the diagnosis of LLL pneumonia, which is a serious condition that requires inpatient care. Therefore, LLL pneumonia is the principal diagnosis. The secondary diagnoses are defined as "all conditions that coexist at the time of admission, that develop subsequently, or that affect the treatment received and/or the length of stay"2. In this case, the patient had bilateral pleural effusion and kidney failure at the time of admission, which are coexisting conditions that affect the treatment received and/or the length of stay. The renal consult documented AKI with ATN, which is a more specific diagnosis than kidney failure and reflects the severity and etiology of the condition. Therefore, AKI with ATN and bilateral pleural effusion are secondary diagnoses. References: CDI Week 2020 QandA: CDI and key performance indicators1 ICD-10-CM Official Guidelines for Coding and Reporting FY 20232

• Question 37:

  Which of the following should be shared to ensure a clear sense of what clinical documentation integrity (CDI) is and the CDI practitioner's role within the organization?

  A. Productivity standards
  B. Review schedule
  C. Milestones
  D. Mission
  D. Mission

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  Explanation/Reference:

  Sharing the mission of the CDI program should be done to ensure a clear sense of what CDI is and the CDI practitioner's role within the organization. The mission statement defines the purpose, goals, and values of the CDI program, and

  how it aligns with the organization's vision and strategy. The mission statement also communicates the benefits and expectations of the CDI program to various stakeholders, such as providers, executives, coders, quality staff, and patients.

  The mission statement can help establish the credibility, professionalism, and identity of the CDI practitioners, and guide their daily activities and decisions 2.

  References: 1: AHIMA CDIP Exam Prep, Fourth Edition, p. 133 3 2: Mission CDI: Guiding goals, values, and principles 1

• Question 38:

  Which of the following diagnosis is MOST likely to trigger a second level review?

  A. Malnutrition
  B. Pneumonia
  C. Heart failure
  D. Acute kidney injury
  A. Malnutrition

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  Explanation/Reference:

  Malnutrition is a diagnosis that is most likely to trigger a second level review because it affects the severity of illness (SOI) and risk of mortality (ROM) of the patient, as well as the reimbursement and quality measures of the hospital.

  Malnutrition also requires clinical validation and clear documentation of its etiology, type, degree, and duration2 References: 1:

  https://www.ahima.org/media/owmhxbv1/cdip_contentoutline_2023_final.pdf 2:

  https://my.ahima.org/store/product?id=67077

• Question 39:

  Based on the flowchart below, at what point might the clinical documentation integrity practitioner (CDIP) enlist the help of the physician advisor/champion?

  

  A. D - No retrospective query opportunity identified
  B. H - Physician fails to respond tocquery
  C. C - Retrospective query opportunity identified
  D. E - Physician agrees with query and documents in MR
  B. H - Physician fails to respond tocquery

• Question 40:

  A patient falls off a ladder and undergoes a right femur procedure. Three weeks later, the patient returns to the hospital for removal of the external fixation device. The ICD-10-CM 7th character code value should indicate

  A. subsequent
  B. sequela
  C. initial
  D. aftercare
  D. aftercare

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  Explanation/Reference:

  The ICD-10-CM 7th character code value should indicate aftercare for a patient who falls off a ladder and undergoes a right femur procedure, and then returns to the hospital for removal of the external fixation device. Aftercare codes are used to capture encounters for follow-up care after completed treatment of an injury or condition, such as removal of external fixation devices, casts, or pins. Aftercare codes are not used for subsequent encounters for complications or infections related to the injury or condition5 References: 1: https://www.ahima.org/media/owmhxbv1/cdip_contentoutline_2023_final.pdf 5: https://my.ahima.org/store/product?id=67077