CDIP Exam Dumps Pass with Updated May-2024 Tests Dumps
CDIP exam questions for practice in 2024 Updated 140 Questions
NEW QUESTION # 33
A patient's progress note states "The patient has chronic systolic heart failure". After reviewing clinical indicators suggestive of an exacerbation of systolic heart failure, the clinical documentation integrity practitioner (CDIP) queries the physician to clarify the current acuity of the diagnosis. Which subsequent documentation in the health record suggests the provider did not understand the query?
- A. The patient has decompensated systolic heart failure.
- B. The patient has chronic systolic heart failure.
- C. The patient has acute on chronic systolic heart failure.
- D. The patient did have an exacerbation of heart failure.
Answer: B
Explanation:
Explanation
According to the AHIMA CDIP Exam Preparation Guide, a query is a communication tool or process used to clarify documentation in the health record for documentation integrity and accurate code assignment1. A query should be clear, concise, and consistent, and should include relevant clinical indicators that support the query1. A query should also provide multiple choice answer options that are supported by clinical indicators and include a non-leading query statement2. In this case, the CDIP queried the physician to clarify the current acuity of the diagnosis of chronic systolic heart failure, based on clinical indicators suggestive of an exacerbation of systolic heart failure. The subsequent documentation in the health record that suggests the provider did not understand the query is A. The patient has chronic systolic heart failure. This documentation does not address the query or provide any additional information about the patient's condition. It simply repeats the same diagnosis that was already documented in the progress note. This documentation does not reflect the patient's true severity of illness, risk of mortality, or reimbursement3. The other options are not correct because they do provide some information about the current acuity of the diagnosis of chronic systolic heart failure, such as acute on chronic, exacerbation, or decompensation. These terms indicate a higher level of severity and complexity than chronic alone. References:
CDIP Exam Preparation Guide - AHIMA
Guidelines for Achieving a Compliant Query Practice (2019 Update) - AHIMA Severity of Illness: What Is It? Why Is It Important? | HCPro
[Q&A: Acute on chronic versus decompensated heart failure | ACDIS]
NEW QUESTION # 34
Given the following ICD-10-CM Alphabetical Index entry:
Ectopic (pregnancy) 008.9
What is the meaning of the parenthesis?
- A. Essential modifiers
- B. Non-essential modifiers
- C. Exclusion notes
- D. Inclusion notes
Answer: B
NEW QUESTION # 35
A patient presents to the emergency room with complaint of cough with thick yellow/greenish sputum, and generalized pain. Admitting vital signs are noted below and sputum culture performed. The patient is admitted with septicemia due to pneumonia and has received 2L of normal saline and piperacillin/ tazobactam. After all results were reviewed, on day 2, the hospitalist continued to document septicemia due to pneumonia.
White blood count BC 18,000
Temperature 101.5
Heart rate 110
Respiratory rate 24
Blood pressure 95/67
Sputum culture (+) klebsiella pneumoniae
Which diagnosis implies that a query was sent and answered?
- A. Severe sepsis with pneumonia due to klebsiella pneumoniae
- B. Sepsis with respiratory failure due to pneumonia
- C. Sepsis with pneumonia due to klebsiella pneumoniae
- D. Septicemia due to klebsiella pneumoniae
Answer: C
Explanation:
Explanation
According to the AHIMA CDIP Exam Preparation Guide, a query is a communication tool or process used to clarify documentation in the health record for documentation integrity and accurate code assignment1. A query should be clear, concise, and consistent, and should include relevant clinical indicators that support the query1. A query should also provide multiple choice answer options that are supported by clinical indicators and include a non-leading query statement2. In this case, the patient presents with signs and symptoms of sepsis, such as fever, tachycardia, tachypnea, hypotension, and elevated white blood count. The patient also has a positive sputum culture for klebsiella pneumoniae, which is the likely source of infection. However, the hospitalist continues to document septicemia due to pneumonia, which is a vague and outdated term that does not reflect the patient's true severity of illness, risk of mortality, or reimbursement3. Therefore, a query to the hospitalist to clarify the diagnosis of sepsis and its etiology is appropriate and compliant. The diagnosis that implies that a query was sent and answered is B. Sepsis with pneumonia due to klebsiella pneumoniae. This diagnosis is more specific and accurate than septicemia due to pneumonia, as it indicates the type of infection (sepsis), the site of infection (pneumonia), and the causal organism (klebsiella pneumoniae). This diagnosis also affects the assignment of DRGs and quality scores. The other options are not correct because they either do not provide enough specificity , or they introduce additional diagnoses that are not supported by the clinical indicators (A and D). References:
CDIP Exam Preparation Guide - AHIMA
Guidelines for Achieving a Compliant Query Practice (2019 Update) - AHIMA Q&A: Three query opportunities related to sepsis infections | ACDIS
[Q&A: Clinical validation of sepsis and clinical criteria | ACDIS]
NEW QUESTION # 36
Educating physicians on severity of illness and risk of mortality is best accomplished by utilizing
- A. the DRG Expert
- B. the case mix index
- C. case studies
- D. physician report cards
Answer: C
Explanation:
Explanation
Educating physicians on severity of illness and risk of mortality is best accomplished by using case studies that demonstrate how documentation affects these indicators and how they impact patient care, quality outcomes, and reimbursement.
References: AHIMA. "CDIP Exam Preparation." AHIMA Press, Chicago, IL, 2017: 97-98.
NEW QUESTION # 37
A 77-year-old male with chronic obstructive pulmonary disease (COPD) is admitted as an inpatient with severe shortness of breath. The patient is placed on oxygen at 2 liters per minute via nasal cannula. History reveals that the patient is on oxygen nightly at home. CXR is unremarkable. The most compliant query is
- A. Patient has COPD, and is on nocturnal oxygen at home and is on continuous oxygen since admission.
Please indicate if you are treating one of these diagnoses: chronic respiratory failure, acute respiratory failure, acute on chronic respiratory failure, unable to determine, other. - B. Patient has COPD, and is on nocturnal oxygen at home and is on continuous oxygen since admission.
Please order further tests so the patient's severity of illness can be captured with the most accurate coding assignment. - C. Patient has COPD and is on oxygen every night at home and has been on continuous oxygen since admission. Based on these indications, please document chronic respiratory failure, acute respiratory failure, acute on chronic respiratory failure.
- D. Patient has COPD and is on oxygen every night at home and has been on continuous oxygen since admission, please document chronic respiratory failure, hypoxia, acute on chronic respiratory failure.
Answer: A
Explanation:
Explanation
According to the AHIMA/ACDIS Query Practice Brief, a compliant query should provide multiple choice answer options that are supported by clinical indicators and include a non-leading query statement1. Option C meets these criteria, as it provides a list of possible diagnoses that are relevant to the patient's condition and asks the provider to indicate which one they are treating. Option C also does not imply or suggest a preferred answer or outcome, and allows the provider to choose unable to determine or other if none of the listed options apply. Option A is not compliant, as it does not provide any answer options and implies that the provider should order more tests to capture a higher severity of illness. Option B is not compliant, as it provides only one answer option and suggests that the provider should document it based on the clinical indicators. Option D is not compliant, as it provides only one answer option and implies that the provider should document it based on the indications. References:
Guidelines for Achieving a Compliant Query Practice (2019 Update) - AHIMA
NEW QUESTION # 38
What type of query may NOT be used in circumstances where only clinical indicators of a condition are present, and the condition/diagnosis has not been documented in the health record?
- A. Yes/No
- B. Open-ended
- C. Multiple-choice
- D. Verbal
Answer: A
Explanation:
Explanation
A yes/no query may not be used in circumstances where only clinical indicators of a condition are present, and the condition/diagnosis has not been documented in the health record because it may lead to leading or suggesting a diagnosis that is not supported by the provider's documentation. A yes/no query should only be used when there is clear and consistent documentation of a condition/diagnosis in the health record, and the query is seeking confirmation or denial of a specific fact or detail related to that condition/diagnosis. A multiple-choice, open-ended, or verbal query may be more appropriate to allow the provider to choose from a list of possible diagnoses, provide additional information, or explain the clinical reasoning behind the documentation. (CDIP Exam Preparation Guide) References:
CDIP Exam Content Outline1
CDIP Exam Preparation Guide2
AHIMA Practice Brief: Guidelines for Achieving a Compliant Query Practice3
NEW QUESTION # 39
The key component of the auditing and monitoring process to ensure provider query response is to
- A. audit individual providers to indicate improvement in health record documentation
- B. review queries retrospectively to ensure that they are completed according to documented Policies and procedures
- C. have a process in place for ongoing education and training of the staff involved in conducting provider queries
- D. make sure that the language in the query is not leading or otherwise inappropriate
Answer: B
NEW QUESTION # 40
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. Query the attending provider
- C. Review the history and physical
- D. Read the nursing admission notes
Answer: C
Explanation:
Explanation
The first step that a clinical documentation integrity practitioner (CDIP) should take to determine the present on admission (POA) status of a stage IV sacral decubitus ulcer documented in the discharge summary is to review the history and physical (H&P) because it is the initial source of information about the patient's condition at the time of admission. The H&P should include a comprehensive physical examination that covers all body systems, including the skin. If the H&P documents the presence of a stage IV sacral decubitus ulcer, then the POA status is "yes". If the H&P does not mention the ulcer, then the CDIP should look for other sources of documentation, such as wound care notes, nursing notes, or progress notes, to see if the ulcer was identified or treated during the hospital stay. If there is no clear evidence of when the ulcer developed, then the CDIP should query the attending provider to clarify the POA status. (CDIP Exam Preparation Guide) References:
CDIP Exam Content Outline1
CDIP Exam Preparation Guide2
Present on Admission Reporting Guidelines3
NEW QUESTION # 41
When are concurrent queries initiated?
- A. Before patient is admitted
- B. While the patient is hospitalized
- C. After the health record has been coded
- D. After discharge of the patient
Answer: B
NEW QUESTION # 42
Which of the following committees should determine the chain of comnfand that will be used to manage physicians who are either unresponsive or uncooperative with the clinical documentation integrity (CDI) program?
- A. Operations
- B. Communications
- C. Compliance
- D. Oversight
Answer: D
Explanation:
Explanation
The oversight committee is responsible for establishing the policies, procedures, and guidelines for the CDI program, as well as monitoring its performance and outcomes. The oversight committee should include representatives from senior leadership, medical staff, coding, quality, compliance, and other relevant stakeholders. The oversight committee should determine the chain of command that will be used to manage physicians who are either unresponsive or uncooperative with the CDI program, as well as the consequences for non-compliance. The other committees are not directly involved in setting the chain of command or the disciplinary actions for the CDI program. The communications committee is responsible for facilitating the information flow and feedback among the CDI staff, providers, coders, and other departments. The operations committee is responsible for managing the day-to-day activities and functions of the CDI staff, such as staffing, training, productivity, and workflow. The compliance committee is responsible for ensuring that the CDI program adheres to the ethical and legal standards and regulations, such as query compliance, documentation integrity, and privacy and security.
NEW QUESTION # 43
Which of the following is the definition of an Excludes 2 note in ICD-10-CM?
- A. Only one code can be assigned to completely describe the condition
- B. This is not a convention found in ICD-10-CM
- C. Neither of the codes can be assigned
- D. Two codes can be used together to completely describe the condition
Answer: D
Explanation:
Explanation
An Excludes 2 note in ICD-10-CM indicates that the condition excluded is not part of the condition represented by the code, but a patient may have both conditions at the same time. When an Excludes 2 note appears under a code, it is acceptable to use both the code and the excluded code together to completely describe the condition. For example, under code R05 Cough, there is an Excludes 2 note for whooping cough (A37.-). This means that a patient can have both a cough and whooping cough at the same time, and both codes can be used together to capture the full clinical picture.
References:
CDIP Exam Content Outline (https://www.ahima.org/media/1z0x0x1a/cdip-exam-content-outline.pdf) ICD-10-CM Features | Diagnosis Coding: Using the ICD-10-CM1
NEW QUESTION # 44
Patient is admitted with oliguria, pulmonary edema, and dehydration. Labs are remarkable for an elevated creatinine of 2.4, with a baseline of 1.1. Patient was hydrated for 48 hours with drop in creatinine. What would the appropriate action be?
- A. Code acute renal failure since symptoms are there and documented
- B. Query the physician to see if acute renal failure is clinically supported
- C. Query the physician to see if acute renal failure with tubular necrosis is supported
- D. No query is needed because the patient was dehydrated
Answer: B
Explanation:
Explanation
The appropriate action in this case is to query the physician to see if acute renal failure is clinically supported.
This is because the patient has signs and symptoms of acute renal failure, such as oliguria, pulmonary edema, and elevated creatinine, but the diagnosis is not documented in the medical record. Acute renal failure is a clinical syndrome characterized by a rapid decline in kidney function and accumulation of metabolic waste products. It can be caused by various factors, such as dehydration, hypovolemia, sepsis, nephrotoxins, or obstruction. Acute renal failure can be classified according to the RIFLE criteria (Risk, Injury, Failure, Loss, End-stage kidney disease) or the AKIN criteria (Acute Kidney Injury Network), which are based on changes in serum creatinine and urine output 23. A query to the physician is needed to confirm or rule out the diagnosis of acute renal failure, specify the etiology and severity of the condition, and document any associated complications or comorbidities. A query to the physician will also improve the accuracy and completeness of the documentation and coding, and reflect the true clinical picture and resource utilization of the patient.
References: 1: AHIMA CDIP Exam Prep, Fourth Edition, p. 133 4 2: Acute Kidney Injury: Diagnosis and Management | AAFP 3: AKIN Classification for Acute Kidney Injury (AKI) - MDCalc
NEW QUESTION # 45
Which of the following is a clinical documentation element supporting a transbronchial biopsy?
- A. Hemoptysis
- B. Length of procedure
- C. Pathology report documenting bronchial tissue
- D. Pathology report documenting alveolar tissue
Answer: D
Explanation:
Explanation
A transbronchial biopsy is a procedure that involves obtaining tissue samples from the alveoli (air sacs) of the lungs through a bronchoscope. A pathology report documenting alveolar tissue is a clinical documentation element that supports a transbronchial biopsy, as it confirms the source and nature of the tissue sample.
References: AHIMA. "CDIP Exam Preparation." AHIMA Press, Chicago, IL, 2017: 55-56.
NEW QUESTION # 46
Which of the following is considered a hospital-acquired condition if not present on admission?
- A. Blood incompatibility
- B. Air leak
- C. Stage I and II pressure ulcers
- D. Diabetes with hypoglycemia
Answer: A
Explanation:
Explanation
Blood incompatibility is considered a hospital-acquired condition if not present on admission, according to the CMS Hospital-Acquired Conditions (HAC) Reduction Program. This program reduces payments to hospitals that have high rates of certain conditions that are acquired during the hospital stay and could have been prevented by following evidence-based guidelines. Blood incompatibility is one of the 14 HAC categories that are included in the program, and it refers to a patient receiving a blood transfusion with incompatible blood type or Rh factor, which can cause serious adverse reactions such as hemolysis, anemia, renal failure, or death 23. Blood incompatibility is a preventable condition that can be avoided by proper blood typing and cross-matching before transfusion, and by following strict protocols and procedures for blood handling and administration 4.
References: 1: AHIMA CDIP Exam Prep, Fourth Edition, p. 133 5 2: Hospital-Acquired Conditions | CMS 1 3: Hospital Acquired Conditions (HACs) - New York State Department of Health 3 4: Transfusion Reactions - Hematology and Oncology - Merck Manuals Professional Edition 6
NEW QUESTION # 47
A patient presents to the emergency department for evaluation after suffering a head injury during a fall. A traumatic subdural hematoma is found on MRI, and the patient is taken directly to the operating room for evacuation. The neurosurgeon performs a burr hole procedure for evacuation of the subdural hematoma. The clot is removed successfully, and the patient is transferred to recovery in stable condition. Which is the correct current procedural terminology (CPT) code assignment for the procedure performed?
- A. 61154 Burr hole(s) with evacuation and/or drainage of hematoma, extradural or subdural
- B. 61140 Burr hole(s) or trephine; with biopsy of brain or intracranial lesion
- C. 61105 Twist drill hole subdural/ventricular puncture
- D. 61108 Twist drill hole(s) for subdural, intracerebral, or ventricular puncture; for evacuation and/or drainage of subdural hematoma
Answer: A
Explanation:
Explanation
According to the CPT code description, 61154 is the appropriate code for a burr hole procedure for evacuation of a subdural hematoma. A burr hole is a small hole made in the skull with a surgical drill to access the brain or its coverings2. A subdural hematoma is a collection of blood between the dura mater and the arachnoid mater, which are two of the three layers that cover the brain3. The evacuation of the hematoma involves removing the clot and relieving the pressure on the brain. The other codes are not applicable for this procedure because they describe different methods of access (twist drill hole) or different purposes (biopsy or puncture)4.
References:
CDI Week 2020 Q&A: CDI and key performance indicators1
Mayo Clinic: Burr hole2
MedlinePlus: Subdural hematoma3
CPT Code Book 20234
NEW QUESTION # 48
A patient presents to the emergency room with acute shortness of breath. The patient has a history of lung cancer that has been treated previously with radiation and chemotherapy. The patient is intubated and placed on mechanical ventilation. A chest x-ray is remarkable for a pleural effusion. A thoracentesis is performed, and the cytology results show malignant cells. Diagnoses on discharge: Acute respiratory failure due to recurrence of small cell carcinoma and malignant pleural effusion. Which coding reference takes precedence for assigning the ICD-10-CM/PCS codes?
- A. AHA Coding Clinic for ICD-10-CM/PCS
- B. AMA CPT Assistant
- C. ICD-10-CM Official Guidelines for Coding and Reporting
- D. Conventions and instructions of the classification for ICD-10-CM/PCS
Answer: D
Explanation:
Explanation
According to the CDIP Exam Content Outline, one of the tasks of a clinical documentation integrity practitioner (CDIP) is to apply coding conventions, guidelines, and definitions for ICD-10-CM/PCS. Coding conventions are the general rules for the use of the classification system, such as the use of abbreviations, punctuation, symbols, and sequencing instructions. Coding guidelines are the official rules for selecting and reporting codes based on the documentation in the health record. Coding definitions are the explanations of the terms and concepts used in the classification system. The conventions and instructions of the classification for ICD-10-CM/PCS take precedence over any other coding reference because they are the primary source of coding rules and standards. The other coding references, such as AMA CPT Assistant, AHA Coding Clinic for ICD-10-CM/PCS, and ICD-10-CM Official Guidelines for Coding and Reporting, are secondary sources that provide additional guidance, clarification, or interpretation of the coding conventions and instructions.
References:
CDIP Exam Content Outline (https://www.ahima.org/media/1z0x0x1a/cdip-exam-content-outline.pdf) ICD-10-CM Features | Diagnosis Coding: Using the ICD-10-CM1
NEW QUESTION # 49
What policies should query professionals follow?
- A. All healthcare entity's policies are the same
- B. AHIMA's policies related to querying
- C. CMS's policies related to querying
- D. Their healthcare entity's internal policies related to querying
Answer: D
Explanation:
Explanation
Query professionals should follow their healthcare entity's internal policies related to querying, as they may vary depending on the organization's size, structure, scope, and goals. The internal policies should be based on industry best practices and standards, such as those provided by AHIMA and ACDIS, as well as applicable laws and regulations, such as those from CMS and OIG. However, AHIMA's and CMS's policies are not binding for all healthcare entities, and they may not address all the specific situations and challenges that query professionals may encounter. Therefore, query professionals should be familiar with their own healthcare entity's policies and procedures for querying, such as the query format, content, timing, delivery method, escalation process, retention, and audit. The other options are incorrect because they do not reflect the diversity and complexity of query policies across different healthcare entities.
NEW QUESTION # 50
Whether or not queries should be kept as a permanent part of the medical record is decided by
- A. organizational policy
- B. state law
- C. federal law
- D. physician preference
Answer: A
Explanation:
Explanation
According to the AHIMA/ACDIS Query Practice Brief, whether or not queries should be kept as a permanent part of the medical record is decided by the organizational policy of each facility1. There is no federal or state law that mandates the retention of queries in the medical record, although some external reviewers may request copies of queries to validate the query wording and compliance2. Physician preference is not a valid factor in determining the query retention policy, as queries should be handled consistently across the organization3. Therefore, the correct answer is D. organizational policy. References:
Guidelines for Achieving a Compliant Query Practice (2019 Update) - AHIMA Q&A: Develop policies regarding query retention | ACDIS Q&A: Keep query retention policies consistent | ACDIS
NEW QUESTION # 51
For inpatients with a discharge principal diagnosis of acute myocardial infarction, aspirin must be taken within
24 hours of arrival unless a contraindication to aspirin is
documented. How should this be documented in the health record?
- A. The name of the medication (aspirin), the date and time it was last administered
- B. The name of the medication (aspirin) and the date it was last administered
- C. The name of the medication (aspirin), the date, time and location where it was last administered
- D. The name of the medication (aspirin), the date and location where it was last administered
Answer: C
Explanation:
Explanation
The name of the medication (aspirin), the date, time and location where it was last administered should be documented in the health record for inpatients with a discharge principal diagnosis of acute myocardial infarction, unless a contraindication to aspirin is documented. This is because aspirin is a core measure for acute myocardial infarction patients, and its administration within 24 hours of arrival is an indicator of quality of care and patient safety. The date, time and location are important to verify that the medication was given within the specified timeframe and to avoid duplication or omission of doses4 References: 1:
https://www.ahima.org/media/owmhxbv1/cdip_contentoutline_2023_final.pdf 4:
https://my.ahima.org/store/product?id=67077
NEW QUESTION # 52
Identify the error in the following query:
This patient's echocardiogram showed an ejection fraction of 25%. The chest x-ray showed congestive heart failure (CHF). The patient was prescribed Lasix and an angiotensin-converting enzyme inhibitor (ACEI). Is this patient's CHF systolic?
- A. The query does not contain clinical indicators.
- B. The query is unclear.
- C. The query is leading.
- D. The query contains irrelevant information.
Answer: C
Explanation:
Explanation
A leading query is one that suggests a specific diagnosis, condition, or treatment to the provider, or implies that a certain response is desired or expected. A leading query can compromise the integrity and accuracy of the documentation and the coded data, and may also raise compliance and ethical issues. A query should be non-leading, meaning that it presents the facts from the health record without bias or influence, and allows the provider to use their clinical judgment to determine the appropriate response.
The query in the question is leading because it implies that the patient's CHF is systolic by asking a yes/no question that only offers one option. A non-leading query would ask an open-ended question that offers multiple options, such as "What type of CHF does this patient have?" or "Please specify the type of CHF:
systolic, diastolic, or combined."
References:
CDIP Exam Preparation Guide, 2021 Edition. AHIMA Press. ISBN: 9781584268530 Guidelines for Achieving a Compliant Query Practice-2022 Update | ACDIS Guidelines for Achieving a Compliant Query Practice (2019 Update) - AHIMA The Provider Query Toolkit: A Guide to Compliant Practices
NEW QUESTION # 53
A clinical documentation integrity practitioner (CDIP) is looking for clarity on whether a diagnosis has been
"ruled in" or "ruled out". Which type of query is the best option?
- A. None
- B. Multiple-choice
- C. Yes/No
- D. Open-ended
Answer: D
Explanation:
Explanation
An open-ended query is a type of query that allows the provider to respond with free text, rather than choosing from a list of options or answering yes or no. An open-ended query is appropriate when the CDIP is looking for clarity on whether a diagnosis has been "ruled in" or "ruled out", because it allows the provider to document the final diagnosis or impression based on the clinical evidence and reasoning. An open-ended query also avoids leading or suggesting a specific diagnosis to the provider, which could compromise the integrity and validity of the documentation. (Guidelines for Achieving a Compliant Query Practice (2019 Update) - AHIMA1) References:
Guidelines for Achieving a Compliant Query Practice (2019 Update) - AHIMA1
NEW QUESTION # 54
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. 470 Major Joint Replacement or Reattachment of Lower Extremity without MCC
- B. 469 Major Joint Replacement or Reattachment of Lower Extremity with MCC
- C. 553 Bone Diseases and Arthropathies with MCC
- D. 179 Respiratory Infections and Inflammations without CC/MCC
Answer: B
Explanation:
Explanation
The correct diagnostic related group (DRG) assignment for this case is 469 Major Joint Replacement or Reattachment of Lower Extremity with MCC. This is because the principal diagnosis is primary osteoarthritis of right hip status post uncomplicated total hip replacement, which belongs to the Major Diagnostic Category (MDC) 08 Diseases and Disorders of the Musculoskeletal System and Connective Tissue. The DRG 469 is assigned to cases with this MDC and a surgical procedure code for major joint replacement or reattachment of lower extremity. The secondary diagnosis of aspiration pneumonia due to choking on liquid episode qualifies as a major complication or comorbidity (MCC), which increases the relative weight and payment for the DRG. The MCC is determined by applying the Medicare Code Editor (MCE) software, which checks the validity and compatibility of the diagnosis codes and assigns them to different severity levels based on the CMS Severity-Diagnosis Related Group (MS-DRG) definitions manual 2.
References: 1: AHIMA CDIP Exam Prep, Fourth Edition, p. 133 3 2: CMS MS-DRG Definitions Manual, Version 38.0, p. 8-9 4
NEW QUESTION # 55
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