CDIP AHIMA (CERTIFIED
DOCUMENTATION INTEGRITY
PRACTITIONER) 2025 QUESTIONS AND
CORRECT DETAILED ANSWERS WITH
RATIONALES (VERIFIED ANSWERS) |
GUARANTEED PASS
A patient has a prostate malignancy that had not been
excised, removed, and still under treatment. The patient
presents to the hospital with irregular heartbeat, malaise
and gross hematuria with large amounts of blood being
passed via the urethra with the inability to urinate. Patient
was noted to have a hemoglobin of 10.8 due to significant
blood loss, the patient was transfused and bladder
irrigation was begun. Following significant irrigation, urine
ran clear.
Based on the above scenario, what is the principal
diagnosis?
a.Blood loss
b.Prostate malignancy
c.Gross hematuria
d.Query warranted to determine the principal Correct
Answer c The diagnosis of gross hematuria should be
selected as principal as the treatment was not
directed toward the malignancy and the rule of
assignment of the principal diagnosis would apply to
this circumstance (AHA Second Quarter 2010).
,The _________ diagnosis is designated and defined as
the condition established after study to be chiefly
responsible for occasioning the admission of the patient to
the hospital
a.Secondary
b.DRG diagnosis
c.Most resource intensive
d.Principal Correct Answer d The Principal diagnosis
should be assigned as the first-listed diagnosis for the
hospital admission as the cause of the hospital stay
after study and evaluation by the responsible
physician (ICD-10-CM Official Coding Guidelines
2016b, 88).
A patient was admitted for ruptured appendix and an
emergent appendectomy was performed. Abscess was
noted on visual exam. During the admission, the patient
had an MI and a stent was placed. What sequencing order
should the procedures be placed in and which should be
principal?
a.The stent placement is more severe and should be first
listed
b.The appendectomy is considered incidental
c.The appendectomy should be first listed
d.Either can be assigned as the principal procedure
Correct Answer c When two definitive procedures have
been performed, the for sequencing should be based
on the procedure most related to the principal
diagnosis as the first procedure to be listed (AHA
Fourth Quarter 2012, 80).
,A patient presents with a myocardial infarction (MI) and
intervention was carried out. It was noted the patient does
have coronary artery disease (CAD). The consulting
physician has stated to staff the CAD should be
sequenced first. What should be the principal diagnosis?
a.CAD
b.MI
c.Chest pain
d.Ill-defined condition Correct Answer b No, the
consultant's advice is not correct. Sequence the AMI
as the principal diagnosis since it is the acute
condition and the reason for the admission. You
should continue to follow correct coding and
reporting practices and report the AMI as the principal
diagnosis (AHA Third Quarter 2009, 9-10. AHA, First
Quarter 2012, 7).
At times, patients present to the hospital with hematoma.
There is noted midline shift of mass effect. Based on the
diagnosis, signs or symptoms, and treatment:
a.The CDS could consider mass effect query
b.The CDS could consider cerebral blood clot query
c.The CDS could consider brain compression query
d.The CDS could have no considerations Correct Answer
c The coder should query the provider and if the
provider clarifies and documents that the mass effect
or midline shift is brain compression, the coder may
then assign a code for the brain compression (AHA
2011, 11).
, If a patient is given Levophed, the patient is most likely
being treated for which of the following diagnoses?
a.Shock
b.Infection
c.Hemorrhage
d.Infarction Correct Answer a This is a treatment for
shock (septic and cardiogenic). (Society of Critical
Care Medicine 2013)
A 68-year-old nursing home patient with status post CVA 2
weeks ago presents via the emergency department with a
1-day history of fever, and elevated blood sugars in the
180-210 range. The patient has stated they have
significant pain of the right buttock since the previous
admission. The patient has a history of diabetes, and is on
long-term insulin. On physical exam, it is noted the patient
had a fever of 101.3 with purulent drainage with exposure
of subcutaneous fat. This type of ulcer can be called a:
a.Stage I
b.Stage II
c.Stage III
d.Stage IV Correct Answer c This is a Stage III ulcer;
Full thickness skin loss. The National Pressure Ulcer
Advisory Panel (NPUAP) has redefined the definition
of a pressure ulcer and the stages of pressure ulcers.
(AHA Fourth Quarter 2008, 132)
This catheter is inserted into larger, deeper veins such as
the subclavian, jugular, or femoral veins. The catheter is
then advanced into the superior vena cava leading directly
to the heart.
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