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CDIP PRACTICE EXAM 2 AHMIA
PRACTICE EXAM 2 QUESTIONS AND
CORRECT ANSWERS | LATEST UPDATE
A physician admits a patient with shortness of breath and chest pain, then treats the patient
with Lasix, oxygen, and Theophylline. The physician's final documented diagnosis for the
patient is acute exacerbation of COPD. What is missing from this diagnosis that would
make it reliable information in the treatment of this patient?
a.No additional information is needed.
b.The type of COPD
c.The reason the patient was treated with Lasix
d.The reason for the Theophylline
✓ -:-
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
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d.None of the above
✓ -:- 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 code d 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 whet her
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
✓ -:- c Clinicians and providers utilize various documents to identify
abnormal temperature, blood pressure, pulse, respiration, oxygen levels,
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and other indicators. These documents are often calle d 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
✓ -:- 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 appr oved 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:
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a.AIDS
b.Asymptomatic HIV
c.Pneumonia
d.Not enough information
✓ -:- 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
✓ -:- 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)
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