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CDIP Practice Exam 1 2025/2026 ACTUAL
EXAM QUESTIONS AND VERIFIED ANSWERS
/GET IT 100% ACCURATE|ALREADY GRADED
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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.
b.I11.
c.I50.23, I
d.I11.0, I50.9 - Answer--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).
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 - Answer--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 - Answer--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
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 - Answer--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 - Answer--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).
An 82-year-old female was walking and inadvertently twisted an ankle causing a minor fall. The patient suffered a fracture of the tibia. The patient was treated and released. It was discussed with the patient to take her hydrocodone as prescribed and continue her medications for osteoporosis, hypertension, and calcium. This fracture:
a.is only a minor setback for the patient
b.has Core measures to meet for quality
c.is coded as pathologic with osteoporosis
d.is coded as a traumatic fracture - Answer--c Osteoporosis with current pathological fracture: A code from category M80, not a traumatic fracture code, should be used for any patient with known osteoporosis who suffers a fracture, even if the patient had a minor fall or trauma, if that fall or trauma would not usually break a normal, healthy bone (ICD-10-CM Official Guidelines for Coding and Reporting 2016b, 51).
A patient presented with pain in the right foot; right big toe. On physical exam, the toe was noted to be red and warm to touch. Laboratory findings show an elevated uric acid. The patient has a previous medication history of colchicine. Which diagnosis below was most likely listed in the diagnostic statement?
a.Arthritis of the right toe
b.Gout of the right toe
c.Cellulitis of the right toe
d.Elevated uric acid - Answer--b Gout inflammation of the joints. This is a metabolic disorder that in acute cases can cause some joints swell up become very painful. Crystals of uric acid that build up mostly in the joints cause the inflammation (NIH n.d.)
This 75-year-old patient has a history of Alzheimer's disease. She is admitted with hypertensive encephalopathy with increased confusion. Her daughter states that she has noticed that she filled her once a day antihypertensive prescription 14 days ago and it still contains the original 30 tablets. This patient most likely could be queried for:
a.Overdosing
b.Underdosing
c.A drug interaction
d.Advancing Alzheimer's - Answer--b Using a prescribed medication less frequently than prescribed, in small doses, or not using the medication as instructed should be documented as "underdosing" by the provider (AHIMA 2015, 56)
observation, code the reason for the surgery as the first reported diagnosis (reason for the encounter), followed by codes for the complications as secondary diagnoses (ICD-10-CM Official Guidelines for Coding and Reporting 2016b, 103).
The CDS performs case review after admission to obtain the:
a.Case Mix Index
b.Core Measure Score
c.working DRG
d.final DRG - Answer--c The CDS performs case review after admission to obtain the "working DRG." Goal should be facility specific but usually 24-48 hours after admission (Hess 2015, 376).
A patient is being seen in the clinic for possible CHF. She has pedal edema and shortness of breath. The physician's office note states rule out, CHF; shortness of breath. The patient's reported diagnosis for this outpatient visit should be:
a.CHF
b.Rule out CHF
c.Shortness of breath
d.Shortness of breath and pedal edema - Answer--d The shortness of breath and pedal edema would be reported for this outpatient visit. Do not code diagnoses documented as "probable," "suspected," "questionable," "rule out," or "working diagnosis" or other similar terms indicating uncertainty. Rather, code the condition(s) to the highest degree of certainty for that encounter/visit, such as symptoms, signs, abnormal test results, or other reason for the visit (ICD-10-CM Official Guidelines for Coding and Reporting 2016b, 104).
A 32-year-old female had a liver transplant 2 years ago. She has been experiencing problems with her kidneys with a GFR of 20 and Stage IV CKD. She is noted to have some jaundice. Based on this:
a.Query should be performed for complication of liver transplant
b.Query should be performed for rejection of liver transplant
c.Query should not be performed as there are no liver complications
d.No additional documentation needed for reporting - Answer--a It is noted that the patient has a previous liver transplant and experiencing jaundice. If a transplant complication such as failure or rejection or other transplant complication is documented, see section I.C. 19.g for information on coding complications of a kidney transplant. If the documentation is unclear as to whether the patient has a complication of the transplant, query the provider (ICD-10-CM Official Guidelines for Coding and Reporting 2016b, 52).
When a patient is admitted for treatment of a secondary malignancy with an active primary site the principal diagnosis should be:
a.The primary malignancy
b.The secondary malignancy
c.Either condition
d.Query should be performed - Answer--b When a patient is admitted because of a primary neoplasm with metastasis and treatment is directed toward the secondary site only, the secondary neoplasm is designated as the principal diagnosis even though the primary malignancy is still present (ICD-10-CM Official Guidelines for Coding and Reporting 2016b, 23).
Assign the following diagnosis code: Permanent atrial fibrillation
I47.2 Ventricular tachycardia
I47.9 Paroxysmal tachycardia, unspecified
I48.0 Paroxysmal atrial fibrillation
I48.1 Persistent atrial fibrillation
I48.2 Chronic atrial fibrillation
a.I47.
b.I47.
c.I48.
d.I48.2 - Answer--d In the ICD-10 alphabetic index, permanent atrial fibrillation is under the main term chronic atrial fibrillation. Atrial fibrillation can be permanent and medicines or other treatments can't restore normal heart rhythm (ICD-10-CM Official Guidelines for Coding and Reporting 2016b; NIH 2014).
a.MCC
b.CC
c.NOS
d.Unspecified - Answer--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,
A 30-year-old cerebral palsy patient was admitted with acute bronchitis, possible pneumonia. In reviewing the diagnoses below what additionally will impact the patient's ICD-10 code assignment.
a.Spasticity
b.Quadriplegia
c.Both A and B
d.None of the above - Answer--c ICD-10 Cerebral palsy and other paralytic syndromes (G80-G83) has additional specificity for spasticity as well as state of paralysis if any (AHIMA 2015, 23).
A 90-year-old female was determined to have a CVA with hemorrhage. The cause of the hemorrhage was determined to be an embolism. What additionally could impact code assignment for the embolism code?
a.Hematemesis
b.Hypertension
c.Site of the hemorrhage
d.Seizure - Answer--c ICD-10 includes the site of the of the hemorrhage for increased specificity.
If a patient undergoes a biopsy immediately before the definitive surgery for a frozen section, how should this be coded with ICD-10-PCS codes?
a.The approach to the definitive surgery
b.Suture method
c.Exploratory surgery
d.Open biopsy and definitive surgery - Answer--d The open biopsy is performed prior to the definitive surgery so that the pathologist can perform a frozen section of the tissue to determine malignancy. Approaches, suturing, and closure are not coded separately. Exploratory surgery is not coded when definitive surgery is performed (Leon-Chisen 2013, 92).
A patient was admitted with diminished responsiveness and hypotension. The patient has a history of hypertension, CVA, CHF, and asthma. The patient suffered a cardiac arrest immediately following admission. The documentation within the record should:
a.List hypotension as first-listed
b.Include the reason for the cardiac arrest
c.Include the date of the previous CVA
d.Type of hypotension - Answer--b Instructional notes in ICD-10-CM for cardiac arrest states "code first underlying condition".
Causes of nonpressure ulcers of the lower limb include:
a.Varicose ulcers
b.Chronic venous hypertension
c.Diabetic ulcer
d.All of the above - Answer--d The causes of lower limb ulcers include Atherosclerosis of lower extremity, Chronic venous hypertension, Diabetic ulcer, Postphlebitic syndrome, Postthrombotic syndrome, Varicose ulcer, and Other as specified (AHIMA 2015, 38).
Eye Opening Response
•Spontaneous-open with blinking at baseline 4 points
•To verbal stimuli, command, speech 3 points
•To pain only (not applied to face) 2 points
•No response 1 point
Verbal Response
•Oriented 5 points
•Confused conversation, but able to answer questions 4 points
Due to the complex nature of severe sepsis, some cases may require querying the provider prior to assignment of the codes (ICD-10-CM Official Guidelines for Coding and Reporting 2016b, 21).
This root operation alters the diameter or route of a tubular body part and completely closes an orifice orlumen; for example, tubal ligation of Fallopian tubes.
a.Dilation
b.Ligation
c.Occlusion
d.Restriction - Answer--c Occlusion is applied to a procedure to close off a tubular body part or orifice via natural orifice or an artificially created orifice. Occlusion includes both intraluminal or extraluminal methods of closing off the body part (Leon-Chisen 2013, 98).
The patient underwent laparotomy to determine if repair was needed to a patient's gastric bypass due to a fall later the day of procedure while in the hospital. No damage was identified and the wound was closed. The CDS is not sure what root operation to use. The most appropriate root operation would be:
a.Inspection
b.Revision
c.Exploration
d.Repair - Answer--a This visual exploration is an inspection and may be performed with or without optical instrumentation. This procedure can be directly or through intervening body layers (Leon-Chisen 2013, 98).
A 32-year-old female fractured her ankle when she stumbled over the shopping cart while pushing it in the supermarket. The orthopedic surgeon recommended open fusion of the right ankle with direct internal fixation, which was performed. Complete the coding of this procedure using the chart below
OSGF _ _ _
ApproachDeviceQualifier0 Open4 Internal Fixation DeviceZ No Qualifier3 Percutaneous5 External Fixation Device4 Percutaneous endoscopic7 Autologous Tissues SubstituteJ Synthetic SubstituteK Nonautologous Tissues SubstituteZ No device
a.OSGF34Z
b.OSGF05Z
c.OSGF04Z
d.OSGF35Z - Answer--c The correct code assignment for Fusion of the right ankle open with internal fixation is OSGF04Z (Leon-Chisen 2013, 102).
One year ago, the patient had a hysterectomy for adenocarcinoma of the uterus. The patient is scheduled for removal of both fallopian tubes due to extension with recent diagnosis of adenocarcinoma of the left fallopian tube. Based on this, the adenocarcinoma of the uterus should be coded as:
a.Adenocarcinoma of the uterus
b.Adenocarcinoma of the uterus, recurrent
c.History of malignant neoplasm of the uterus
d.Not coded - Answer--c When a primary malignancy has been previously excised or eradicated from its site, there is no further treatment directed to that site, and there is no evidence of any existing primary malignancy, a code from category Z85, Personal history of malignant neoplasm, should be used to indicate the former site of the malignancy (ICD-10-CM Official Guidelines for Coding and Reporting, 2016b).
The adenocarcinoma of the fallopian tube should be coded as
a.Adenocarcinoma of the fallopian tube, primary
b.Adenocarcinoma of the fallopian tube, secondary
c.History of malignant neoplasm of the fallopian tube
d.Not coded - Answer--b Any mention of extension, invasion, or metastasis to another site (in this case uterus with extension to fallopian tubes) is coded as a secondary malignant neoplasm to that site. The secondary site may be the principal or first-listed with the Z85 code used as a secondary code (ICD-10- CM Official Guidelines for Coding and Reporting, 2016b).
Modifier 59 provides guidance that a service is distinct and separate. Beginning January 2015, 4 new modifiers were created to provide greater reporting specificity in situations where modifier 59 was previously reported and may be utilized in lieu of modifier 59 whenever possible. These modifiers are
a.XA, XB, XC, XD
•Who asks queries and to whom,
•The hospital's responsibility in supporting the query process,
•Acceptable ways to respond to queries, as well as the physician's responsibility in responding to queries
Oversight of the CDI program should be comprised of the physician advisor or leader for clinical documentation and CDI, and the manager of the CDI program, along with:
a.Executive leadership
b.Service line directors
c.Patient Financial Services
d.Information Technology - Answer--a A CDI program should have support for physician advisor or leader for clinical documentation and CDI, and the manager of the CDI program, along with executive leadership (Hess 2015, 105).
Anywhere Hospital has been experiencing problems interacting with the medical staff. Anywhere should utilize which committee to assist with these problems?
a.Compliance committee
b.Executive committee
c.Medical staff committee
d.Oversight committee - Answer--a A CDI program should have support for physician advisor or leader for clinical documentation and CDI, and the manager of the CDI program, along with executive leadership (Hess 2015, 105).
A new or restructuring CDI program should ask:
a.How can the bottom line be increased?
b.How many queries must be performed for financial success?
c.Why does clinical documentation need to be improved?
d.How fast can this be done? - Answer--c Understanding why a facility want to improve clinical documentation to support the vision of the program for all involved in the effort (Hess 2015, 205).
A new CDI program is experiencing conflicts within the health record between a consulting physician and the physician ultimately responsible for the documentation of the patient. The physician ultimately responsible is the:
a.Consulting physician
b.Hospitalist
c.Attending physician
d.Intensivist - Answer--c The attending physicians are responsible for the documentation that supports the final diagnostic statement for the patient (42 CFR 412.46). The attending physician should be asked to provide the final documented response when inconsistencies arise within the record (42 CFR 412.46; Hess 2015, 29).
Which of the following would generally be found in a query to a physician?
a.Health record number and demographic information
b.Name and contact number of the individual initiating the query and account number
c.Date query initiated and date query must be completed
d.Demographic information and name and contact number of individual initiating the query - Answer--b It is recommended that the healthcare entity's policy address the query format. A query generally includes the following information: patient name, admission date or date of service, health record number, account number, date query initiated, name and contact information of the individual initiating the query, and statement of the issue in the form of a question along with clinical indicators specified from the chart (for example, history and physical states urosepsis, lab reports WBC of 14,400, emergency department report fever of 102°F) (Shaw and Carter, 2014; Schraffenberger and Kuehn 2011, 45-46).
In conducting a qualitative review, the clinical documentation specialist sees that the nursing staff has documented the patient's skin integrity on admission to support the presence of a stage I pressure ulcer. However, the physician's documentation is unclear as to whether this condition was present on admission. How should the clinical documentation specialist proceed?
a.Note the condition as present on admission
b.Query the physician to determine if the condition was present on admission
a.Tell the physicians he has the best relationships with the physicians and can tell them what to document
b.Document specifically what is needed in the health record for the patient
c.Not tell or ask a treating physician to document something specifically
d.Respond to queries on patients they both have seen in the past 3 years - Answer--c Within small communities patients may migrate from physician to physician. However, it is imperative that physician executives limit their documentation only to those patients whom they are treating. In particular, physician executives may not tell or ask a treating physician to document something specifically in the patient's record Physician executives can ask open-ended questions based on the criteria. (Hess 2015, 30).
Communication within a CDI program is important from the very beginning. The three key concepts that should be considered in communication for the program are who communicates it, what is communicated, and_____:
a.When is it communicated?
b.How will it be communicated?
c.How long will it be communicated?
d.All of the above - Answer--b It is important to communicate information on the CDI process prior to starting or operationalizing a CDI program. Key concepts to cover are:
•WHO communicates it—From whom will communications come?
•HOW will it be communicated—What media will the CDI program use?
•WHAT is communicated—What information will the CDI staff communicate? (Hess 2015, 109)
To ensure a CDI program is successful and sustainable it should have:
a.Physician leadership
b.Metrics
c.A CDI manager
d.Resources such as CDI software - Answer--a Physician leadership is essential to a successful and sustainable CDI program (Marco and Buchman 2003; Keogh and Martin 2004; Hess 2015, 122).
Dr. Bach has noted he has been increasingly negotiating problems between coders, CDS staff, and physicians. Dr. Bach stated he will no longer do this as this is not the role of the physician advisor:
a.This is an accurate statement
b.This is an inaccurate statement
c.The CDI manager should begin to fill this role
d.The HIM or coding manager should begin to fill this role - Answer--b It is important for the physician to undergo training and fully understand their role. The leader should be available to assist in particularly challenging reviews and when the CDI specialist encounters a problematic physician (Hess 2015, 122).
The role of the physician advisor for CDI should require a minimum of:
a.No formal training
b.10 hours of training
c.40 hours of training
d.1 year of coding experience - Answer--c Physician advisors should participate in a minimum of 40 hours of training regarding CDI (Hess 2015, 124).
A patient has a stage III pressure ulcer noted in the ED. While the patient is in the hospital for 6 days, the ulcer progresses to stage IV. The correct POA assignment would be:
a.Y-yes
b.N-no
c.U-unknown
d.None of the above - Answer--a The pressure ulcer was noted on admission. Assign "Y" for conditions diagnosed during the admission that were clearly present but not diagnosed until after admission occurred (ICD-10-CM Official Guidelines for Coding and Reporting 2016b, 109).
The following query was found in a patient's health record. Which of the answers best applies to this query?
