CDIP CORE EXAM 2026 TEST QUESTIONS AND SOLUTIONS
GRADED A+
✔✔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, wound - ✔✔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 - ✔✔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 (ICD-10-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
GRADED A+
✔✔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, wound - ✔✔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 - ✔✔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 (ICD-10-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
