CDIP PRACTICE REAL EXAM 2 STUDY
GUIDE 2026 COMPLETE TEST BANK WITH
ANSWERS
◉ If the physician does not document the diagnosis, the coding
professional cannot assume the patient has a diagnosis based solely
on
a.An abnormal lab finding
b.Abnormal pathology reports
c.Both A and B
d.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 records
b.Vital sign flowsheets
c.Both A and B
d.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 all
a.Cooperating parties
b.Governing bodies
c.Coding associations
d.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).
,◉ A patient was admitted with HIV and pneumocystic carini. The
patient should have a principal diagnosis in ICD-10 of:
a.AIDS
b.Asymptomatic HIV
c.Pneumonia
d.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, Minor
b.Extreme, Major, Moderate, Minor
c.Extreme, Major, Moderate, Minimal
d.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 surgery
b.The reason for admission
c.Either the reason for the outpatient surgery or the reason for
admission
d.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).
◉ 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
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)
GUIDE 2026 COMPLETE TEST BANK WITH
ANSWERS
◉ If the physician does not document the diagnosis, the coding
professional cannot assume the patient has a diagnosis based solely
on
a.An abnormal lab finding
b.Abnormal pathology reports
c.Both A and B
d.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 records
b.Vital sign flowsheets
c.Both A and B
d.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 all
a.Cooperating parties
b.Governing bodies
c.Coding associations
d.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).
,◉ A patient was admitted with HIV and pneumocystic carini. The
patient should have a principal diagnosis in ICD-10 of:
a.AIDS
b.Asymptomatic HIV
c.Pneumonia
d.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, Minor
b.Extreme, Major, Moderate, Minor
c.Extreme, Major, Moderate, Minimal
d.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 surgery
b.The reason for admission
c.Either the reason for the outpatient surgery or the reason for
admission
d.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).
◉ 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
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)
