Which of the following is the definition of an Excludes 2 note in ICD-10-CM?

• A.Neither of the codes can be assigned
• B.Two codes can be used together to completely describe the condition
• C.Only one code can be assigned to completely describe the condition
• D.This is not a convention found in ICD-10-CM

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What type of laboratory test is a creatinine test?

• A.Chemistry
• B.Microbiology
• C.Serology
• D.Hematology

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A patient receives a blood transfusion after a 400 ml blood loss during surgery. The clinical documentation integrity practitioner (CDIP) queries the physician for an associated diagnosis. The facility does not maintain queries as part of the permanent health record. What does the physician need to document for the CDIP to record the query as answered and agreed?

• A.That the blood loss was not clinically significant
• B.The associated diagnosis and the clinical rationale in the progress notes
• C.A cause-and-effect relationship between anemia and the underlying cause
• D.The associated diagnosis directly on the query form

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Which of the following is an example of a hospital-acquired condition when not present on admission?

• A.Iatrogenic pneumothorax with lung biopsy
• B.Iatrogenic pneumothorax with venous catheterization
• C.Pressure ulcer stage II
• D.Pressure ulcer stage III

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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.Read the nursing admission notes
• C.Query the attending provider
• D.Review the history and physical

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