CDIP - Certified Documentation Improvement Practitioner Clinical Coding Practice Questions and Answers

Question 1

A patient is admitted with acute exacerbation of COPD and pneumonia.
The patient also has a history of hypertension and type 2 diabetes.
After study, the physician determines the principal diagnosis is pneumonia.
Which of the following is the correct action for the CDI practitioner regarding the principal diagnosis selection?

Accepted Answer

Query the physician for clarification, as either the COPD exacerbation or pneumonia could be principal.

Answer

Agree with the physician's selection of pneumonia as the principal diagnosis.

Answer

Change the principal diagnosis to COPD exacerbation as it is a more severe condition.

Answer

Assign both pneumonia and COPD exacerbation as co-principal diagnoses.

Question 2

A CDI specialist reviews a record where the physician has documented 'urosepsis.' Laboratory results show a positive urine culture for E. coli and systemic inflammatory response syndrome (SIRS) criteria are met. What is the most appropriate next step for the CDI specialist?

Accepted Answer

Query the physician to clarify if the patient has sepsis, linking the clinical indicators and the term 'urosepsis'.

Answer

Assign the code for sepsis due to E. coli.

Answer

Code for a urinary tract infection as 'urosepsis' is a non-specific term.

Answer

Report the 'urosepsis' code as documented by the physician.

Question 3

Which of the following is a primary goal of clinical coding practice within a CDI program?

Accepted Answer

To ensure the coded data accurately reflects the patient's clinical picture and severity of illness.

Answer

To maximize hospital reimbursement by upcoding whenever possible.

Answer

To educate physicians on how to document to achieve the highest possible Case Mix Index (CMI).

Answer

To decrease the number of physician queries by making assumptions based on clinical indicators.

Question 4

A 78-year-old patient is admitted for a hip fracture after a fall. The medical record also contains a note from a consulting cardiologist stating 'Heart failure, likely diastolic.' The patient is treated with diuretics. How should the CDI specialist address the heart failure documentation?

Accepted Answer

Query the attending physician to confirm the diagnosis and specificity of the heart failure.

Answer

Ignore the cardiologist's note as it is from a consultant.

Answer

Code diastolic heart failure as it is documented by a specialist.

Answer

Assign a code for unspecified heart failure since the diagnosis is not certain.

Question 5

The assignment of a complication or comorbidity (CC) or a major complication or comorbidity (MCC) to a patient's record directly impacts the:

Accepted Answer

MS-DRG (Medicare Severity-Diagnosis Related Group).

Answer

Patient's length of stay.

Answer

Quality scores of the attending physician.

Answer

Number of queries sent to providers.

Question 6

According to the ICD-10-CM Official Guidelines for Coding and Reporting, what takes precedence in code assignment?

Accepted Answer

The Tabular List instructions and conventions.

Answer

The Alphabetic Index.

Answer

AHA Coding Clinic advice.

Answer

The CDI specialist's clinical judgment.