Online Access Free CDIP Practice Test

A query should be generated when the documentation is

• A.legible
• B.complete
• C.consistent
• D.conflicting

A 45-year-old female is admitted after sustaining a femur fracture. Orthopedics is consulted and performs an open reduction internal fixation (ORIF) of the femur without complication. Nursing documents the patient has a body mass index of 42 kg/m2. The clinical documentation integrity practitioner (CDIP) determines a query is needed to capture a diagnosis associated with the body mass index so it can be reported. Which of the following is the MOST compliant query based on the most recent AHIIMA/ACDIS query practice brief?

• A.Nursing documents the BMI is 42 kg/m2. Please consider if any of the following diagnoses should be added to the health record to support this finding: morbid obesity; obesity; other diagnosis (please state)
• B.Nursing documents the BMI is 42 kg/m2. In order to capture a co-morbid condition (CC) to increase reimbursement, please add 'morbid obesity with BMI 42 kg/m2' to your next progress note.
• C.Nursing documents the BMI is 42 kg/m2. To increase the severity of illness and risk of mortality, please add 'morbid obesity with BMI 42 kg/m2' to your next progress note.
• D.Nursing documents the BMI is 42 kg/m2. Can you please clarify if the patient's morbid obesity was present on admission and add the diagnosis to future progress notes?

The correct coding for insertion of a dialysis catheter into the right internal jugular vein with the tip ending in the cavoatrial junction is

• A.05HP33Z Insertion of infusion device into right external jugular vein, percutaneous approach
• B.02H633Z Insertion of infusion device into right atrium, percutaneous approach
• C.02HV33Z Insertion of infusion device into superior vena cava, percutaneous approach
• D.05HM33Z Insertion of infusion device into right internal jugular vein, percutaneous approach

A clinical documentation integrity practitioner (CDIP) must determine the present on admission (POA) status of a stage IV sacral decubitus ulcer documented in the discharge summary. What is the first step that should be taken?

• A.Look for wound care documentation
• B.Review the history and physical
• C.Read the nursing admission notes
• D.Query the attending provider

An otherwise healthy male was admitted to undergo a total hip replacement as treatment for ongoing primary osteoarthritis of the right hip. During the post-operative period, the patient choked on liquids which resulted in aspiration pneumonia as shown on chest x-ray.
Intravenous antibiotics were administered, and the pneumonia was
monitored for improvement with two additional chest x-rays. The patient was discharged to home in stable condition on post-operative day 5.
Final Diagnoses:
1. Primary osteoarthritis of right hip status post uncomplicated total hip replacement
2. Aspiration pneumonia due to choking on liquid episode
What is the correct diagnostic related group assignment?

• A.553 Bone Diseases and Arthropathies with MCC
• B.179 Respiratory Infections and Inflammations without CC/MCC
• C.469 Major Joint Replacement or Reattachment of Lower Extremity with MCC
• D.470 Major Joint Replacement or Reattachment of Lower Extremity without MCC