CDIP Domain 1: Clinical Coding Practice
exam 2023|61 Questions & Answers|
100% Accurate Graded A
Coding Clinic - -Valuable reference tool for coders that is published by AHA each
quarter
-CPT - -Current Procedural Terminology
-MS-DRGs - -Medicare Severity-Diagnosis Related Groups
-CPT Assistant - -Monthly publication by the AMA that provides coding advice for CPT
coding scenarios
-Encoder Nosology - -Provides coding professionals from the encoder company that
are available to help answer tough coding questions
-History & Physical - -Provides the initial chief complaint and initial impressions of the
provider when the patient is first admitted. It also has a comprehensive physical review
of the patient's body systems and vital signs, and provides the initial treatment plan,
medications, and tests that are being ordered to treat the patient.
-Progress Notes - -Provide information about what is going on with the patient on a
day-to-day basis; they should include the diagnoses that are being treated as well as any
information about any changes in the patient's well-being and tests/procedures being
performed.
-Operative and Pathology Reports - -Summarize the invasive procedures performed
and any samples that are removed from the patient's body
-Pathology report - -Provides detailed information from the pathologist of the facility
as to the status of the tissues or organs removed from the patient's body
-Encoder - -Specialty software used to facilitate the assignment of diagnostic and
procedural codes according to the rules of the coding system
-What is the value of utilizing coding software? - -It facilitates accurate coding by
providing links to coding resources, groups diagnosis and procedure codes to the correct
, MS-DRG, and provides edits with additional information for the coder to consider when
placing codes into the encoder
-Principal diagnosis - -Diagnosis that, after study, is the reason for the patient's
admission to the hospital.
-Secondary diagnoses - -Additional supporting information for the conditions the
patient is being cared for
-MCC - -Major Complication or Comorbidity
-CC - -Complication or Comorbidity
-CMI - -Case Mix Index
-LOS - -Length of Stay
-Complication - -A condition arising during the hospital stay that prolongs the LOS by
at least one day in approximately 75% of the cases
-Comorbidity - -A pre-existing condition which because of its presence with the
principal diagnosis will increase the LOS by at least one day in 75% of the cases
-Primary procedures - -Procedure codes that best represent the procedure that has
been performed
-Secondary procedures - -Do not typically impact the MS-DRG; however, they are
important for capturing the details of the care the patient has received while in the
hospital.
-Coding conventions for ICD-10-CM - -General rules for the use of the classification
independent of the guidelines
-Letter that ICD-10 utilizes as a placeholder for certain codes - -X
-Excludes1 - -Indicates that the code excluded should never be used with the code
above the Excludes1 note.
-Excludes2 - -Indicates that, when appropriate, it is acceptable to use both the code
and the excluded code together.
exam 2023|61 Questions & Answers|
100% Accurate Graded A
Coding Clinic - -Valuable reference tool for coders that is published by AHA each
quarter
-CPT - -Current Procedural Terminology
-MS-DRGs - -Medicare Severity-Diagnosis Related Groups
-CPT Assistant - -Monthly publication by the AMA that provides coding advice for CPT
coding scenarios
-Encoder Nosology - -Provides coding professionals from the encoder company that
are available to help answer tough coding questions
-History & Physical - -Provides the initial chief complaint and initial impressions of the
provider when the patient is first admitted. It also has a comprehensive physical review
of the patient's body systems and vital signs, and provides the initial treatment plan,
medications, and tests that are being ordered to treat the patient.
-Progress Notes - -Provide information about what is going on with the patient on a
day-to-day basis; they should include the diagnoses that are being treated as well as any
information about any changes in the patient's well-being and tests/procedures being
performed.
-Operative and Pathology Reports - -Summarize the invasive procedures performed
and any samples that are removed from the patient's body
-Pathology report - -Provides detailed information from the pathologist of the facility
as to the status of the tissues or organs removed from the patient's body
-Encoder - -Specialty software used to facilitate the assignment of diagnostic and
procedural codes according to the rules of the coding system
-What is the value of utilizing coding software? - -It facilitates accurate coding by
providing links to coding resources, groups diagnosis and procedure codes to the correct
, MS-DRG, and provides edits with additional information for the coder to consider when
placing codes into the encoder
-Principal diagnosis - -Diagnosis that, after study, is the reason for the patient's
admission to the hospital.
-Secondary diagnoses - -Additional supporting information for the conditions the
patient is being cared for
-MCC - -Major Complication or Comorbidity
-CC - -Complication or Comorbidity
-CMI - -Case Mix Index
-LOS - -Length of Stay
-Complication - -A condition arising during the hospital stay that prolongs the LOS by
at least one day in approximately 75% of the cases
-Comorbidity - -A pre-existing condition which because of its presence with the
principal diagnosis will increase the LOS by at least one day in 75% of the cases
-Primary procedures - -Procedure codes that best represent the procedure that has
been performed
-Secondary procedures - -Do not typically impact the MS-DRG; however, they are
important for capturing the details of the care the patient has received while in the
hospital.
-Coding conventions for ICD-10-CM - -General rules for the use of the classification
independent of the guidelines
-Letter that ICD-10 utilizes as a placeholder for certain codes - -X
-Excludes1 - -Indicates that the code excluded should never be used with the code
above the Excludes1 note.
-Excludes2 - -Indicates that, when appropriate, it is acceptable to use both the code
and the excluded code together.
