CDIP PRACTICE EXAMINATION 2026
QUESTIONS WITH ANSWERS GRADED
A+
◍ If the physician does not document the diagnosis, the coding professional
cannot assume the patient has a diagnosis based solely ona.An abnormal lab
findingb.Abnormal pathology reportsc.Both A and Bd.None of the above.
Answer: 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 recordsb.Vital sign
flowsheetsc.Both A and Bd.None of the above.
Answer: 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 alla.Cooperating partiesb.Governing bodiesc.Coding
associationsd.Work independently to develop coding guidelines.
Answer: 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).
◍ eMAR.
Answer: Electronic medication administration record
◍ A patient was admitted with HIV and pneumocystic carini. The patient
should have a principal diagnosis in ICD-10 of:a.AIDSb.Asymptomatic
HIVc.Pneumoniad.Not enough information.
Answer: 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, Minorb.Extreme, Major, Moderate, Minorc.Extreme, Major,
Moderate, Minimald.Excessive, Major.
Answer: b The APR-DRG system is distributed into levels (subclasses)
similar to MS-DRGs. 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
surgeryb.The reason for admissionc.Either the reason for the outpatient
surgery or the reason for admissiond.None of the above.
Answer: 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).
, ◍ PACS.
Answer: Picture archive and communication system
◍ 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-DRGsb.AP-DRGsc.APR-DRGsd.CPT-DRGs.
Answer: 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)
◍ CPOE.
Answer: Computerized provider/practitioner/physician order entry
◍ 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.Pneumoniab.Arrhythmiac.Atrial fibrillationd.Both a and c.
Answer: 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).
Answer: c The cooperating parties developed and approved
QUESTIONS WITH ANSWERS GRADED
A+
◍ If the physician does not document the diagnosis, the coding professional
cannot assume the patient has a diagnosis based solely ona.An abnormal lab
findingb.Abnormal pathology reportsc.Both A and Bd.None of the above.
Answer: 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 recordsb.Vital sign
flowsheetsc.Both A and Bd.None of the above.
Answer: 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 alla.Cooperating partiesb.Governing bodiesc.Coding
associationsd.Work independently to develop coding guidelines.
Answer: 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).
◍ eMAR.
Answer: Electronic medication administration record
◍ A patient was admitted with HIV and pneumocystic carini. The patient
should have a principal diagnosis in ICD-10 of:a.AIDSb.Asymptomatic
HIVc.Pneumoniad.Not enough information.
Answer: 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, Minorb.Extreme, Major, Moderate, Minorc.Extreme, Major,
Moderate, Minimald.Excessive, Major.
Answer: b The APR-DRG system is distributed into levels (subclasses)
similar to MS-DRGs. 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
surgeryb.The reason for admissionc.Either the reason for the outpatient
surgery or the reason for admissiond.None of the above.
Answer: 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).
, ◍ PACS.
Answer: Picture archive and communication system
◍ 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-DRGsb.AP-DRGsc.APR-DRGsd.CPT-DRGs.
Answer: 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)
◍ CPOE.
Answer: Computerized provider/practitioner/physician order entry
◍ 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.Pneumoniab.Arrhythmiac.Atrial fibrillationd.Both a and c.
Answer: 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).
Answer: c The cooperating parties developed and approved
