Clinical Documentation Improvement Test Bank
Course Introduction
Clinical Documentation Improvement focuses on the principles and practices necessary to ensure accurate, thorough, and timely medical documentation within healthcare settings. This course covers the critical role of documentation in patient care, billing, legal compliance, and quality initiatives. Students will learn strategies to identify documentation gaps, use clinical terminology appropriately, and collaborate effectively with healthcare providers to enhance the clarity and completeness of patient records. Emphasis is placed on regulatory standards, electronic health record systems, coding accuracy, and the impact of documentation on patient outcomes and healthcare reimbursement.
Recommended Textbook
The Complete Diagnosis Coding Solution 3rd Edition by Shelley Safian
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23 Chapters
1144 Verified Questions
1144 Flashcards
Source URL: https://quizplus.com/study-set/2701
Page 2
Chapter 1: Introduction to Diagnostic Coding
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50 Verified Questions
50 Flashcards
Source URL: https://quizplus.com/quiz/53903
Sample Questions
Q1) Asthma is an example of a(n) ____________.
A) diagnosis
B) procedure
C) indication
D) opinion
Answer: A
Q2) Which of the following professional organizations has a code of ethics for coders to follow?
A) AAPC
B) AHIMA
C) Both AAPC and AHIMA
D) Neither AAPC nor AHIMA
Answer: C
Q3) The physician's notes state, "Chest congestion, possible pneumonia." The coder in the physician's office should:
A) code for pneumonia.
B) code for chest congestion.
C) query the physician.
D) All of these
Answer: B
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Chapter 2: Introduction to ICD-10-CM
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50 Flashcards
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Sample Questions
Q1) Roseanne is diagnosed with rat-bite fever. This is coded with which of the following codes?
A) A25.0
B) A25.1
C) A25.9
D) D44.3
Answer: C
Q2) George's broken foot did not heal properly. Today's encounter is coded as a(n):
A) current condition.
B) injury.
C) late effect.
D) adverse reaction.
Answer: C
Q3) Which of the following external cause codes is used to report the status of a patient who was injured while participating in a volunteer activity?
A) Y99.1
B) Y99.2
C) Y99.3
D) Y99.4
Answer: B
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Chapter 3: General Guidelines and Notations
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47 Verified Questions
47 Flashcards
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Sample Questions
Q1) A statement in which the physician uses the word versus between two diagnostic statements is known as a:
A) differential diagnosis.
B) possible diagnosis.
C) rule-out diagnosis.
D) suspected diagnosis.
Answer: A
Q2) NOS stands for:
A) no ovary status.
B) not optional selection.
C) not otherwise specified.
D) not otherwise stated.
Answer: C
Q3) A primary malignant neoplasm of the right femur is coded as:
A) D16.20.
B) C79.51.
C) C40.20.
D) C40.21.
Answer: D
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Page 5
Chapter 4: Coding Infectious Diseases
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50 Verified Questions
50 Flashcards
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Sample Questions
Q1) When coding for high-risk heterosexual behavior, what code is assigned?
A) Z20.6
B) Z11.4
C) Z72.51
D) Z72.811
Q2) The diagnosis of severe sepsis must include:
A) identification of the underlying infection.
B) which organ system failed.
C) the age of the patient.
D) identification of the underlying infection and which organ failed.
Q3) The correct code for the bubonic plague is:
A) A20.0.
B) A20.1.
C) A20.2.
D) A20.7.
Q4) When a pathogen has infected multiple countries, this is referred to as (a[n]):
A) epidemic.
B) endemic.
C) pandemic.
D) nosocomial.
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Chapter 5: Coding Neoplasms
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Sample Questions
Q1) What is the correct code assigned for a personal history of breast cancer?
A) Z85.1
B) Z85.2
C) Z85.3
D) Z85.4
Q2) Arthur was diagnosed with cancer of the right acoustic nerve. How is this coded?
A) C72.40
B) C72.41
C) C72.42
D) C72.59
Q3) The term mass is often used to describe a:
A) benign tumor.
B) cyst.
C) malignant tumor.
D) All of these
Q4) What is the correct code assigned for an atypical nevus of the trunk?
A) D22.0
B) D22.10
C) D22.39
D) D22.5
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Chapter 6: Coding Diseases of the Blood and Immune Mechanism
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49 Verified Questions
49 Flashcards
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Sample Questions
Q1) What is the correct code assigned for abnormal hemoglobin?
A) D58.0
B) D58.1
C) D58.2
D) D58.8
Q2) What blood test is used to test for kidney function?
A) Bicarbonate
B) Blood culture
C) Blood differential
D) Blood urea nitrogen
Q3) Mary Jo Dallin was seen in the office today for lethargy lasting for about 2 weeks. After some workup, it was found that Mary Jo has mixed hemoglobinopathy. What is/are the correct code(s) to report?
A) R53.83, D58.8
B) R53.83, D59.4
C) D58.2
D) D59.4
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Page 8
Chapter 7: Coding Conditions of the Endocrine and Metabolic Systems
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49 Flashcards
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Sample Questions
Q1) What is the correct code assigned for a patient with abetalipoproteinemia?
A) E78.0
B) E78.1
C) E78.5
D) E78.6
Q2) Which of the following glands releases serotonin?
A) Adrenal
B) Pineal
C) Pituitary
D) Thyroid
Q3) Which of the following conditions is a disorder of water metabolism that is the result of an ADH deficiency?
A) Type 1 DM
B) Diabetes insipidus
C) Secondary DM
D) Gestational DM
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Chapter 8: Coding Mental and Behavioral Disorders
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50 Verified Questions
50 Flashcards
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Sample Questions
Q1) What is the correct code for vascular dementia without behavioral disturbance?
A) F01.50
B) F01.51
C) F02.80
D) F02.81
Q2) What is the correct code assigned for paranoid reaction?
A) F21
B) F22
C) F23
D) F24
Q3) What is the correct code for opioid use with withdrawal?
A) F11.90
B) F11.92
C) F11.920
D) F11.93
Q4) What is the correct code for type II bipolar disorder?
A) F31.70
B) F31.72
C) F31.81
D) F31.89
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Chapter 9: Coding Nervous System Conditions
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50 Flashcards
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Sample Questions
Q1) A patient suffering from weakness of one side of the body has which condition?
A) Hemiplegia
B) Hemiparesis
C) Monoplegia
D) Monoparesis
Q2) Which layer of the meninges contains a network of nerves and blood vessels?
A) Arachnoid mater
B) Basal mater
C) Dura mater
D) Pia mater
Q3) Which lobes control speech, critical thinking, and memory?
A) Frontal lobes
B) Parietal lobes
C) Temporal lobes
D) Occipital lobes
Q4) What is the correct code for a patient who has paralysis of both upper limbs?
A) G83.0
B) G83.10
C) G83.11
D) G83.20
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Chapter 10: Coding Diseases of the Eye and Adnexa
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50 Flashcards
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Sample Questions
Q1) What are the correct codes for a patient with blepharitis of the left lower eyelid and chronic dacryocystitis of the right lacrimal passage?
A) H01.005, H04.411
B) H01.005, H04.412
C) H01.006, H04.411
D) H01.006, H04.412
Q2) What is/are the correct code(s) assigned for a patient with hypertensive retinopathy of the left eye?
A) H35.031
B) H35.032, I10
C) H35.033, I10
D) H35.039, I11
Q3) Which of the following is not a sign or symptom of retinal detachment?
A) Floaters
B) Photopsia
C) Headache
D) Loss of vision
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Chapter 11: Coding Diseases of the Auditory System Ears
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50 Verified Questions
50 Flashcards
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Sample Questions
Q1) What is another name for earwax?
A) Cerumen
B) Vestibule
C) Cochlea
D) Saccule
Q2) Approximately how many decibels of hearing loss must a patient have for at least a short period of time in order to qualify for a cochlear implant?
A) 60
B) 70
C) 80
D) 100
Q3) Callin Collin is seen in the office today for bilateral hyperacusis and bilateral perceptive hearing loss. What are the correct codes?
A) H93.231, H90.0
B) H93.232, H90.3
C) H93.233, H90.3
D) H93.239, H90.8
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Page 13
Chapter 12: Coding Circulatory Conditions
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50 Flashcards
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Sample Questions
Q1) What is the correct code for a patient who is in cardiac arrest?
A) I46.2
B) I46.8
C) I46.9
D) I45.9
Q2) Which of the following is also known as a stroke?
A) Left heart failure
B) Right heart failure
C) Cerebral infarct
D) Cerebrovascular accident
Q3) Chest pain is also referred to as:
A) angina.
B) cardiac arrest.
C) dyspnea.
D) arrhythmia.
Q4) Which part of the heart is known as the pacemaker?
A) AV node
B) SA node
C) Mitral valve
D) Bicuspid valve
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Chapter 13: Coding Respiratory Conditions
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50 Flashcards
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Sample Questions
Q1) Getting rid of carbon dioxide is known as:
A) expiration.
B) inspiration.
C) aspiration.
D) respiration.
Q2) What is the correct code for acute epiglottitis with obstruction?
A) J05.0
B) J05.1
C) J05.10
D) J05.11
Q3) What is the term commonly used for breathing?
A) Expiration
B) Inspiration
C) Aspiration
D) Respiration
Q4) What is the correct code for a persistent air leak?
A) J93.81
B) J93.82
C) J93.83
D) J93.9
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Chapter 14: Coding Diseases of the Digestive System
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50 Flashcards
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Sample Questions
Q1) Another name for the oral cavity is the:
A) cheeks.
B) lips.
C) mouth.
D) tongue.
Q2) Which part of the pharynx lies behind the oral cavity?
A) Nasopharynx
B) Oropharynx
C) Hypopharynx
D) Laryngopharynx
Q3) Which of the following is a fleshy tissue suspended from the soft palate at the opening of the throat?
A) Palatine tonsils
B) Uvula
C) Pharyngeal tonsils
D) Salivary glands
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16
Chapter 15: Coding Diseases of the Integumentary System
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50 Flashcards
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Sample Questions
Q1) Which of the following lesions is flaky exfoliated epidermis?
A) Macule
B) Nevus
C) Scale
D) Bulla
Q2) Which of the following layers of skin contains blood vessels, nerves, glands, hair follicles, and lymph channels?
A) Dermis
B) Epidermis
C) Subcutaneous tissue
D) Fat
Q3) Which of the following is the code assigned for nail dystrophy?
A) L60.0
B) L60.1
C) L60.2
D) L60.3
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17
Chapter 16: Coding Muscular Conditions
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Sample Questions
Q1) Which of the following is not an abdominal muscle?
A) Oblique muscle, external
B) Pyramidalis
C) Rectus abdominis
D) Cremaster
Q2) What type of muscle action describes muscle movement by a conscious decision?
A) Voluntary
B) Involuntary
C) Deliberate
D) Erratic
Q3) Which of the following is not a shoulder muscle?
A) Deltoid
B) Trochlea
C) Infraspinatus
D) Teres major
Q4) Which of the following muscles raises a body part?
A) Levator muscle
B) Intrinsic muscle
C) Extensor muscle
D) Flexor muscle
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Chapter 17: Coding Skeletal Conditions
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Sample Questions
Q1) Which of the following types of fractures happens when the bone has been placed inward?
A) Avulsion
B) Burst
C) Comminuted
D) Depressed
Q2) Which of the following seventh characters is used to show that the patient was seen for an initial encounter for treatment of a fracture?
A) A
B) D
C) G
D) K
Q3) Which of the following seventh characters is used to show that the patient was seen to check for healing of a fracture?
A) A
B) D
C) G
D) K
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19
Chapter 18: Coding Diseases of the Urinary System
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Sample Questions
Q1) Which of the following is a lower urinary tract infection?
A) Cystitis
B) Urethritis
C) Both of these
D) Neither of these
Q2) How many types of dialysis are there?
A) 1
B) 2
C) 3
D) 4
Q3) What is the correct code for a patient being seen for kidney transplant rejection?
A) T86.00
B) T86.01
C) T86.10
D) T86.11
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Page 20
Chapter 19: Coding for Obstetrics and Gynecology
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Sample Questions
Q1) What is the correct code for a patient with primary genital syphilis?
A) A51.0
B) A51.1
C) A51.2
D) A51.31
Q2) What percentage of women of childbearing age are affected by endometriosis in the United States?
A) 2-10 percent
B) 11-18 percent
C) 19-25 percent
D) 26-30 percent
Q3) What is the correct code for 40 weeks gestation of pregnancy?
A) Z3A.36
B) Z3A.38
C) Z3A.40
D) Z3A.42
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21
Chapter 20: Coding Congenital and Pediatric Conditions
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Sample Questions
Q1) What is the correct code for respiratory distress syndrome of a newborn?
A) P22.0
B) P22.1
C) P22.8
D) P22.9
Q2) Which of the following terms is used to describe an abnormal or unexpected condition?
A) Anomaly
B) Congenital
C) Malformation
D) Preexisting
Q3) Which of the following is used to obtain placental tissue samples?
A) Amniocentesis
B) Karyotype
C) Chorionic villus sampling
D) Pedigree
Q4) What does the abbreviation LBW stand for?
A) Low baby weight
B) Low birth weight
C) Light baby weight
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Chapter 21: Coding Injuries, Poisonings, and Certain Other
Consequences of External Causes
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Sample Questions
Q1) An injury in which all the layers of the skin are traumatically torn away from the body is known as a(n):
A) abrasion.
B) avulsion.
C) laceration.
D) puncture wound.
Q2) Sophia Smith was weeding her garden this morning and got a splinter stuck in her right thumb. What codes are assigned?
A) S61.041A, W45.8XXD, Y92.017XA, Y93.H2
B) S61.041A, W45.8XXA, Y92.017, Y93.H2
C) S61.042A, W45.8XXD, Y92.017, Y93.H2
D) S61.042A, W45.8XXA, Y92.017, Y93.H2
Q3) What is the correct code for an adverse effect of niacin?
A) T46.7X1A
B) T46.7X3A
C) T46.7X4A
D) T46.7X5A
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Page 23
Chapter 22: Factors Influencing Health Status and Contact
With Health Services
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Sample Questions
Q1) What is the correct code for a volunteer whole blood donor?
A) Z52.000
B) Z52.010
C) Z52.090
D) Z52.098
Q2) What is the correct code for an office visit for immunizations?
A) Z22
B) Z23
C) Z28.01
D) Z28.9
Q3) A patient visits the doctor's office for a testicular cancer screening. During the examination, the doctor discovers an atrophied right testis. What is/are the correct code(s) assignment?
A) Z12.71
B) Z12.72
C) N50.0
D) Z12.71, N50.0
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Page 24
Chapter 23: Hospital Inpatient Diagnosis Coding
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Sample Questions
Q1) Which of the following is signed by the attending physician?
A) Discharge summary
B) Hospital course
C) Discharge instructions
D) Discharge disposition
Q2) In outpatient coding, which of the following are you permitted to code?
A) Rule out
B) Probable
C) Suspected
D) None of these
Q3) Carolyn Crimson was admitted for acute appendicitis. The day after surgery, she had a hemorrhage and hematoma and was taken back to surgery. Which is the correct POA assignment for this case?
A) K35.80-Y, K91.840-N
B) K35.80-N, K91.841-N
C) K35.80-Y, K91.840-Y
D) K35.80-Y, K91.841-N
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