1|Page
CDIP PRACTICE EXAM 1 NEWEST 2026 ACTUAL EXAM COMPLETE
150 QUESTIONS AND CORRECT ANSWERS WITH RATIONALES
(VERIFIED ANSWERS) |ALREADY GRADED A+
The procedure that was performed for the definitive treatment (rather than
the diagnosis) of the main condition, or a complication of the condition is the:
a.Chief procedure
b.Principal treatment
c.Principal procedure
d.Comorbidity - ANSWER-c The principal procedure is the procedure
that was performed for the definitive treatment (rather than the
diagnosis) of the main condition or a complication of the condition
(Shaw and Carter 2014; LaTour et al. 2013, 432,940).
A physician query may not be appropriate in which of the following
instances?
a.Diagnosis of viral pneumonia noted in the progress notes and sputum
cultures showing
Haemophilus influenzae
b.Discharge summary indicates chronic renal failure but the progress notes
document acute renal failure throughout the stay
c.Acute respiratory failure in a patient whose lab report findings appear to
not support this diagnosis
,2|Page
d.Diagnosis of chest pain and abnormal cardiac enzymes indicative of an
AMI - ANSWER-c A query may not be appropriate because the clinical
information or clinical picture does not appear to support the
documentation of a condition or procedure. In situations in which the
provider's documented diagnosis does not appear to be supported by
clinical findings, a healthcare entity's policies can provide guidance on
a process for addressing the issue without querying the attending
physician (Shaw and Carter 2014; Schraffenberger and Kuehn 2011,
348).
Who is responsible for the content, quality, and signing of the discharge
summary?
a.Attending physician
b.Head nurse
c.Consulting physician
d.Admitting nurse - ANSWER-a The physician principally responsible for
the patient's hospital care generally dictates the discharge summary.
However, a resident, physician assistant, or nurse practitioner who is
being supervised by the attending physician may complete this task.
Regardless of who documents it, the attending physician is
responsible for the content and quality of the summary and must date
and sign it Shaw and Carter 2014; Fahrenholz and Russo 2013, 284).
,3|Page
A coder notes that the patient is taking prescribed Haldol. The final diagnoses
on the progress notes include diabetes mellitus, acute pharyngitis, and
malnutrition. What condition might the coder suspect the patient has that the
physician should be queried to confirm?
a.Insomnia
b.Hypertension
c.Mental or behavioral problems
d.Rheumatoid arthritis - ANSWER-c Haldol is a drug frequently
administered for behavior or mental conditions, so the coder would
suspect mental or behavioral problems for this patient. The physician
must be queried to confirm the diagnosis. Documentation is needed in
the record to support the coding of the mental or behavioral problem
(Shaw and Carter 2014; Schraffenberger and Kuehn 2011, 285).
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 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
, 4|Page
d.Note the condition as not present on admission - ANSWER-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).
A query should be generated when the health record documentation:
a.Is conflicting, imprecise, incomplete, illegible, ambiguous, or inconsistent
b.Describes or is associated with clinical indicators without a definitive
relationship to an underlying diagnosis
c.Provides a diagnosis without underlying clinical validation
d.All of the above - ANSWER-d 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
CDIP PRACTICE EXAM 1 NEWEST 2026 ACTUAL EXAM COMPLETE
150 QUESTIONS AND CORRECT ANSWERS WITH RATIONALES
(VERIFIED ANSWERS) |ALREADY GRADED A+
The procedure that was performed for the definitive treatment (rather than
the diagnosis) of the main condition, or a complication of the condition is the:
a.Chief procedure
b.Principal treatment
c.Principal procedure
d.Comorbidity - ANSWER-c The principal procedure is the procedure
that was performed for the definitive treatment (rather than the
diagnosis) of the main condition or a complication of the condition
(Shaw and Carter 2014; LaTour et al. 2013, 432,940).
A physician query may not be appropriate in which of the following
instances?
a.Diagnosis of viral pneumonia noted in the progress notes and sputum
cultures showing
Haemophilus influenzae
b.Discharge summary indicates chronic renal failure but the progress notes
document acute renal failure throughout the stay
c.Acute respiratory failure in a patient whose lab report findings appear to
not support this diagnosis
,2|Page
d.Diagnosis of chest pain and abnormal cardiac enzymes indicative of an
AMI - ANSWER-c A query may not be appropriate because the clinical
information or clinical picture does not appear to support the
documentation of a condition or procedure. In situations in which the
provider's documented diagnosis does not appear to be supported by
clinical findings, a healthcare entity's policies can provide guidance on
a process for addressing the issue without querying the attending
physician (Shaw and Carter 2014; Schraffenberger and Kuehn 2011,
348).
Who is responsible for the content, quality, and signing of the discharge
summary?
a.Attending physician
b.Head nurse
c.Consulting physician
d.Admitting nurse - ANSWER-a The physician principally responsible for
the patient's hospital care generally dictates the discharge summary.
However, a resident, physician assistant, or nurse practitioner who is
being supervised by the attending physician may complete this task.
Regardless of who documents it, the attending physician is
responsible for the content and quality of the summary and must date
and sign it Shaw and Carter 2014; Fahrenholz and Russo 2013, 284).
,3|Page
A coder notes that the patient is taking prescribed Haldol. The final diagnoses
on the progress notes include diabetes mellitus, acute pharyngitis, and
malnutrition. What condition might the coder suspect the patient has that the
physician should be queried to confirm?
a.Insomnia
b.Hypertension
c.Mental or behavioral problems
d.Rheumatoid arthritis - ANSWER-c Haldol is a drug frequently
administered for behavior or mental conditions, so the coder would
suspect mental or behavioral problems for this patient. The physician
must be queried to confirm the diagnosis. Documentation is needed in
the record to support the coding of the mental or behavioral problem
(Shaw and Carter 2014; Schraffenberger and Kuehn 2011, 285).
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 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
, 4|Page
d.Note the condition as not present on admission - ANSWER-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).
A query should be generated when the health record documentation:
a.Is conflicting, imprecise, incomplete, illegible, ambiguous, or inconsistent
b.Describes or is associated with clinical indicators without a definitive
relationship to an underlying diagnosis
c.Provides a diagnosis without underlying clinical validation
d.All of the above - ANSWER-d 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
