CDIP PRACTICE REAL EXAM 1 WITH
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In conducting a qualitative review, the clinical documentation specialist sees
... [Show More] 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
c.Note the condition as unknown on admission
d.Note the condition as not present on admission - ANSWERS-b As a result of the
disparity in documentation practices by providers, querying has become a common
communication and educational method to advocate proper documentation practices.
Queries can be made in situations when there is clinical evidence for a higher degree of
specificity or severity (Shaw and Carter 2014; Schraffenberger and Kuehn 2011, 42).
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 - ANSWERS-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).
In ICD-10-PCS, what value is used if there is a character that does not apply to a given
code?
a.X
b.Z
c.0
d.- - ANSWERS-b All ICD-10-PCS codes must be seven characters, and a character
cannot be left blank. If a value does not exist for a given character, the Z is used as the
value (Shaw and Carter 2014; Kuehn and Jorwic 2013, 5).
In performing query reconciliation, it is determined that queries initiated on the floor in
the concurrent process are not addressed retrospectively at discharge. This is:
a.appropriate, as queries should not be made retrospectively
b.appropriate, as queries should not be a concern once the patient is discharged
c.inappropriate, as queries should be generated or addressed by the coder
retrospectively [Show Less]