CDIP FINAL EXAM 2026 UPDATED QUESTIONS AND
SOLUTIONS GRADED A+
✔✔One year ago, the patient had a hysterectomy for adenocarcinoma of the uterus.
The patient is scheduled for removal of both fallopian tubes due to extension with recent
diagnosis of adenocarcinoma of the left fallopian tube. Based on this, the
adenocarcinoma of the uterus should be coded as:
a.Adenocarcinoma of the uterus
b.Adenocarcinoma of the uterus, recurrent
c.History of malignant neoplasm of the uterus
d.Not coded - ✔✔c When a primary malignancy has been previously excised or
eradicated from its site, there is no further treatment directed to that site, and there is no
evidence of any existing primary malignancy, a code from category Z85, Personal
history of malignant neoplasm, should be used to indicate the former site of the
malignancy (ICD-10-CM Official Guidelines for Coding and Reporting, 2016b).
✔✔The adenocarcinoma of the fallopian tube should be coded as
a.Adenocarcinoma of the fallopian tube, primary
b.Adenocarcinoma of the fallopian tube, secondary
c.History of malignant neoplasm of the fallopian tube
d.Not coded - ✔✔b Any mention of extension, invasion, or metastasis to another site (in
this case uterus with extension to fallopian tubes) is coded as a secondary malignant
neoplasm to that site. The secondary site may be the principal or first-listed with the Z85
code used as a secondary code (ICD-10-CM Official Guidelines for Coding and
Reporting, 2016b).
✔✔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, CC47
c.XE, XS, XP, XU
d.44, 45, 45, 47 - ✔✔c Modifiers, XE, XS, XP, XU, were created to be utilized in lieu of
modifier 59 to provide increased specificity (CMS 2014a).
✔✔E/M services refer to visits and consultations furnished by physicians and the
following qualified NPPs:
a.Physical therapists; clinical nurse specialists; certified nurse midwives; and physician
assistants
b.Nurse practitioners; clinical nurse specialists; certified nurse midwives; and physician
assistants
c.Speech therapists, clinical nurse specialists; certified nurse midwives; and physician
assistants
,d.These services are furnished for physicians only - ✔✔b E/M services refer to visits
and consultations furnished by physicians and the following qualified NPPs:
•Nurse practitioners;
•Clinical nurse specialists;
•Certified nurse midwives; and
•Physician assistants.
A NPP's Medicare benefit must permit him or her to bill for E/M services, and the
services must be furnished within the scope of practice in the State in which the NPP
practices in order to receive payment from Medicare (CMS 2015a).
✔✔Every organization should develop a query policy and procedure that is specific to
its organization and that addresses when to ask queries, who asks queries and to
whom, the hospital's responsibility in supporting the query process, acceptable ways to
respond to queries, and ___________
a.How to optimize revenue
b.The physician's responsibility in responding to queries
c.Number of queries to ask
d.DRGs to target for revenue impact - ✔✔b Every organization should develop a query
policy and procedure that is specific to its organization and that addresses:
•When to ask queries,
•Who asks queries and to whom,
•The hospital's responsibility in supporting the query process,
•Acceptable ways to respond to queries, as well as the physician's responsibility in
responding to queries
✔✔Oversight of the CDI program should be comprised of the physician advisor or
leader for clinical documentation and CDI, and the manager of the CDI program, along
with:
a.Executive leadership
b.Service line directors
c.Patient Financial Services
d.Information Technology - ✔✔a A CDI program should have support for physician
advisor or leader for clinical documentation and CDI, and the manager of the CDI
program, along with executive leadership (Hess 2015, 105).
✔✔Anywhere Hospital has been experiencing problems interacting with the medical
staff. Anywhere should utilize which committee to assist with these problems?
a.Compliance committee
b.Executive committee
c.Medical staff committee
d.Oversight committee - ✔✔a A CDI program should have support for physician advisor
or leader for clinical documentation and CDI, and the manager of the CDI program,
along with executive leadership (Hess 2015, 105).
✔✔A new or restructuring CDI program should ask:
, a.How can the bottom line be increased?
b.How many queries must be performed for financial success?
c.Why does clinical documentation need to be improved?
d.How fast can this be done? - ✔✔c Understanding why a facility want to improve
clinical documentation to support the vision of the program for all involved in the effort
(Hess 2015, 205).
✔✔A new CDI program is experiencing conflicts within the health record between a
consulting physician and the physician ultimately responsible for the documentation of
the patient. The physician ultimately responsible is the:
a.Consulting physician
b.Hospitalist
c.Attending physician
d.Intensivist - ✔✔c The attending physicians are responsible for the documentation that
supports the final diagnostic statement for the patient (42 CFR 412.46). The attending
physician should be asked to provide the final documented response when
inconsistencies arise within the record (42 CFR 412.46; Hess 2015, 29).
✔✔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 - ✔✔b It is recommended that the healthcare entity's policy address the query
format. A query generally includes the following information: patient name, admission
date or date of service, 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 (for
example, history and physical states urosepsis, lab reports WBC of 14,400, emergency
department report fever of 102°F) (Shaw and Carter, 2014; Schraffenberger and Kuehn
2011, 45-46).
✔✔In conducting a qualitative review, the clinical documentation specialist sees that the
nursing staff has documented the patient's skin integrity on admission to support the
presence of a stage I pressure ulcer. However, the physician's documentation is unclear
as to whether this condition was present on admission. How should the clinical
documentation specialist proceed?
a.Note the condition as present on admission
b.Query the physician to determine if the condition was present on admission
c.Note the condition as unknown on admission
d.Note the condition as not present on admission - ✔✔b As a result of the disparity in
documentation practices by providers, querying has become a common communication
and educational method to advocate proper documentation practices. Queries can be
made in situations when there is clinical evidence for a higher degree of specificity or
severity (Shaw and Carter 2014; Schraffenberger and Kuehn 2011, 42).
SOLUTIONS GRADED A+
✔✔One year ago, the patient had a hysterectomy for adenocarcinoma of the uterus.
The patient is scheduled for removal of both fallopian tubes due to extension with recent
diagnosis of adenocarcinoma of the left fallopian tube. Based on this, the
adenocarcinoma of the uterus should be coded as:
a.Adenocarcinoma of the uterus
b.Adenocarcinoma of the uterus, recurrent
c.History of malignant neoplasm of the uterus
d.Not coded - ✔✔c When a primary malignancy has been previously excised or
eradicated from its site, there is no further treatment directed to that site, and there is no
evidence of any existing primary malignancy, a code from category Z85, Personal
history of malignant neoplasm, should be used to indicate the former site of the
malignancy (ICD-10-CM Official Guidelines for Coding and Reporting, 2016b).
✔✔The adenocarcinoma of the fallopian tube should be coded as
a.Adenocarcinoma of the fallopian tube, primary
b.Adenocarcinoma of the fallopian tube, secondary
c.History of malignant neoplasm of the fallopian tube
d.Not coded - ✔✔b Any mention of extension, invasion, or metastasis to another site (in
this case uterus with extension to fallopian tubes) is coded as a secondary malignant
neoplasm to that site. The secondary site may be the principal or first-listed with the Z85
code used as a secondary code (ICD-10-CM Official Guidelines for Coding and
Reporting, 2016b).
✔✔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, CC47
c.XE, XS, XP, XU
d.44, 45, 45, 47 - ✔✔c Modifiers, XE, XS, XP, XU, were created to be utilized in lieu of
modifier 59 to provide increased specificity (CMS 2014a).
✔✔E/M services refer to visits and consultations furnished by physicians and the
following qualified NPPs:
a.Physical therapists; clinical nurse specialists; certified nurse midwives; and physician
assistants
b.Nurse practitioners; clinical nurse specialists; certified nurse midwives; and physician
assistants
c.Speech therapists, clinical nurse specialists; certified nurse midwives; and physician
assistants
,d.These services are furnished for physicians only - ✔✔b E/M services refer to visits
and consultations furnished by physicians and the following qualified NPPs:
•Nurse practitioners;
•Clinical nurse specialists;
•Certified nurse midwives; and
•Physician assistants.
A NPP's Medicare benefit must permit him or her to bill for E/M services, and the
services must be furnished within the scope of practice in the State in which the NPP
practices in order to receive payment from Medicare (CMS 2015a).
✔✔Every organization should develop a query policy and procedure that is specific to
its organization and that addresses when to ask queries, who asks queries and to
whom, the hospital's responsibility in supporting the query process, acceptable ways to
respond to queries, and ___________
a.How to optimize revenue
b.The physician's responsibility in responding to queries
c.Number of queries to ask
d.DRGs to target for revenue impact - ✔✔b Every organization should develop a query
policy and procedure that is specific to its organization and that addresses:
•When to ask queries,
•Who asks queries and to whom,
•The hospital's responsibility in supporting the query process,
•Acceptable ways to respond to queries, as well as the physician's responsibility in
responding to queries
✔✔Oversight of the CDI program should be comprised of the physician advisor or
leader for clinical documentation and CDI, and the manager of the CDI program, along
with:
a.Executive leadership
b.Service line directors
c.Patient Financial Services
d.Information Technology - ✔✔a A CDI program should have support for physician
advisor or leader for clinical documentation and CDI, and the manager of the CDI
program, along with executive leadership (Hess 2015, 105).
✔✔Anywhere Hospital has been experiencing problems interacting with the medical
staff. Anywhere should utilize which committee to assist with these problems?
a.Compliance committee
b.Executive committee
c.Medical staff committee
d.Oversight committee - ✔✔a A CDI program should have support for physician advisor
or leader for clinical documentation and CDI, and the manager of the CDI program,
along with executive leadership (Hess 2015, 105).
✔✔A new or restructuring CDI program should ask:
, a.How can the bottom line be increased?
b.How many queries must be performed for financial success?
c.Why does clinical documentation need to be improved?
d.How fast can this be done? - ✔✔c Understanding why a facility want to improve
clinical documentation to support the vision of the program for all involved in the effort
(Hess 2015, 205).
✔✔A new CDI program is experiencing conflicts within the health record between a
consulting physician and the physician ultimately responsible for the documentation of
the patient. The physician ultimately responsible is the:
a.Consulting physician
b.Hospitalist
c.Attending physician
d.Intensivist - ✔✔c The attending physicians are responsible for the documentation that
supports the final diagnostic statement for the patient (42 CFR 412.46). The attending
physician should be asked to provide the final documented response when
inconsistencies arise within the record (42 CFR 412.46; Hess 2015, 29).
✔✔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 - ✔✔b It is recommended that the healthcare entity's policy address the query
format. A query generally includes the following information: patient name, admission
date or date of service, 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 (for
example, history and physical states urosepsis, lab reports WBC of 14,400, emergency
department report fever of 102°F) (Shaw and Carter, 2014; Schraffenberger and Kuehn
2011, 45-46).
✔✔In conducting a qualitative review, the clinical documentation specialist sees that the
nursing staff has documented the patient's skin integrity on admission to support the
presence of a stage I pressure ulcer. However, the physician's documentation is unclear
as to whether this condition was present on admission. How should the clinical
documentation specialist proceed?
a.Note the condition as present on admission
b.Query the physician to determine if the condition was present on admission
c.Note the condition as unknown on admission
d.Note the condition as not present on admission - ✔✔b As a result of the disparity in
documentation practices by providers, querying has become a common communication
and educational method to advocate proper documentation practices. Queries can be
made in situations when there is clinical evidence for a higher degree of specificity or
severity (Shaw and Carter 2014; Schraffenberger and Kuehn 2011, 42).
