CDIP Practice -Exam 1
Which symbol of punctuation is used in the Tabular List to enclose synonyms, alternative wording, or
explanatory phrases?
a.Parentheses
b.Brackets
c.Colon
d.Comma - a Punctuation is widely used in coding. Brackets are used in the Alphabetic Index to
identify manifestation codes as well as to enclose synonyms, alternative wording or explanatory phrases.
(ICD-10-CM Official Guidelines for Coding and Reporting 2016b, 8)
Assign the best answer to complete the following sentence. The CPT codes for treatment of fractures:
a.Use the terminology "manipulation" rather than "reduction" of fracture
b.Include internal fixation in all codes
c.Do not include application of cast
d.Do not differentiate between open and closed treatment; CPT only specifies the site of the fracture -
a Manipulation refers to the attempted reduction or restoration of a dislocated joint or fracture
(Smith 2015, 84)
In CPT, if a patient has two lacerations of the arm that are repaired with simple closures, the coder would
assign:
a.Two CPT codes expressing each laceration repair
b.One CPT code for the largest laceration
c.One CPT code, adding the lengths of the lacerations together
d.One CPT code for the most complex closure - c When multiple wounds are repaired with the
same closure type (for example, simple), lengths of the wounds in the same classification and from all
anatomical sites that are grouped together into the same code descriptor should be added together
(Smith 2015, 67).
Patient admitted for laparoscopic repair of right diaphragmatic hernia. Assign the ICD-10-PCS procedure
code for this surgery.
0BQR4ZZ Repair right diaphragm, percutaneous endoscopic approach
,0BQROZZ Repair right diaphragm, open approach
0BQS4ZZ Repair left diaphragm, percutaneous endoscopic approach
0BQSOZZ Repair left diaphragm, open approach
a.0BQR4ZZ
b.0BQR0ZZ
c.0BQS4ZZ
d.0BQS0ZZ - a Surgery is the only treatment for diaphragmatic hernias. ICD-10-PCS code 0BQR4ZZ,
is used for laparoscopic repair of diaphragmatic hernia (Garvin 2015, 192, 284)
Assign code(s) for the following diagnosis: Congestive heart failure due to hypertension.
I10 Essential (primary) hypertension
I11.9 Hypertensive heart disease without heart failure
I11.0 Hypertensive heart disease with heart failure
I50.9 Heart failure, unspecified
I50.1 Left ventricular failure
I50.20 Unspecified systolic (congestive) heart failure
I50.21 Acute systolic (congestive) heart failure
I50.22 Chronic systolic (congestive) heart failure
I50.23 Acute on chronic systolic (congestive) heart failure
a.I10, I50.9
b.I11.0
c.I50.23, I10
d.I11.0, I50.9 - d Heart conditions are assigned a combination code when a causal relationship is
stated (due to hypertension) or implied (hypertensive). Use an additional code to identify the type of
heart failure in those patients with heart failure (ICD-10-CM Official Guidelines for Coding and Reporting
2016b, 41).
When trying to determine if documentation is present to substantiate status asthmaticus, the coder
should review the record for what terms and phrases?
a.Intractable pneumonia
,b.Refractory asthma and severe, intractable wheezing
c.Airway obstruction relieved by bronchodilators
d.Limited but pronounced wheezing - b Status asthmaticus is defined as continual wheezing in
spite of therapy (Leon-Chisen 2013, 230).
Gastrointestinal bleeding can manifest as:
a.Hematemesis, which indicates acute upper gastrointestinal hemorrhage
b.Petechia
c.Vomiting
d.Constipation, which indicates upper or lower gastrointestinal hemorrhage - a Gastrointestinal
bleeding manifests itself in several ways. These are hematemesis, melena, occult bleeding,
hematochezia (Leon-Chisen 2013, 244).
Which types of pacemaker devices have a unique ICD-10-PCS code.
a.Dual chamber rate responsive
b.Single chamber, single chamber rate responsive, and dual chamber
c.Multiple chamber
d.Multiple chamber rate responsive - b The three types of pacemakers are single chamber, single
chamber rate responsive, and dual chamber. A single chamber uses a single lead; a dual chamber
requires two leads, one in the atrium and one in the ventricle. The leads should also be coded (Leon-
Chisen 2013, 416-418).
Mechanical ventilation codes require consideration of which of the following?
a.The time when a tracheal tube is inserted
b.The replacement of an endotracheal tube
c.The start time of endotracheal tube insertion followed by mechanical ventilation
d.Mechanical ventilation during surgery - c Codes for mechanical ventilation indicate whether the
patient was on mechanical ventilation for less than 24 hours, 24-96 consecutive hours and greater than
96 consecutive hours. The start time for calculating the duration begins with the start time of
endotracheal tube insertion as the best method, followed by mechanical ventilation or the time that a
patient who is on mechanical ventilation is admitted. The time ends with discontinuance of mechanical
ventilation (Leon-Chisen 2013, 239-240).
, Abbreviations can be a source of patient safety issues due to misinterpretation and miscommunication.
Abbreviations in the health record:
a.Are not permitted by Joint Commission standards
b.Should have only one meaning
c.Enhance patient safety
d.Are critical to an electronic health record system - b The Joint Commission has established a
cautious quality approach to the use of abbreviations in all its accredited organizations. To comply, every
healthcare organization should strive to limit or eliminate the use of abbreviations by developing an
organizationspecific abbreviation list so that only those abbreviations approved by the organization are
used. When more than one meaning for an approved abbreviation exists, an organization should choose
only one meaning or context in which the abbreviation is to be used (Shaw and Carter 2014; Brodnik et
al. 2012, 180-181).
In ICD-10-PCS, what value is used if there is a character that does not apply to a given code?
a.X
b.Z
c.0
d.- - b All ICD-10-PCS codes must be seven characters, and a character cannot be left blank. If a
value does not exist for a given character, the Z is used as the value (Shaw and Carter 2014; Kuehn and
Jorwic 2013, 5).
When the documentation in the medical record is insufficient to assign a more specific code, a _______
code is assigned.
a.MCC
b.CC
c.NOS
d.Unspecified - d When documentation in the record is not available to assign a more specific
code, an unspecified code is assigned (ICD-10-CM Official Guidelines for Coding and Reporting 2016b,
10)
