Clinical Coding Flashcards
7 cards from real CCDS practice questions. Tap to flip, then mark Knew It or Still Learning — missed cards come back until you master them.
Read the first 7 Clinical Coding flashcards as text
In ICD-10-CM, which guideline governs how to code two conditions when a patient has both Type 2 diabetes mellitus and chronic kidney disease stage 3?
Answer: Use combination code E11.22 for diabetic CKD
ICD-10-CM provides combination code E11.22 (Type 2 diabetes mellitus with diabetic chronic kidney disease stage 3) that captures both conditions in a single code.
Which Present on Admission (POA) indicator is assigned when documentation is insufficient to determine if a condition was present at the time of inpatient admission?
Answer: U
POA indicator 'U' is assigned when documentation is insufficient to determine if the condition was present on admission.
A patient is admitted after a fall from a ladder at a construction site. The injury is a closed fracture of the femoral shaft. Which ICD-10-CM code captures the external cause of the initial encounter?
Answer: W11.XXXA
W11.XXXA represents a fall on and from a ladder, initial encounter, which correctly captures the external cause mechanism.
Under the Uniform Hospital Discharge Data Set (UHDDS), the principal diagnosis is defined as the condition established after study to be chiefly responsible for what?
Answer: Occasioning the admission to the hospital
UHDDS defines the principal diagnosis as the condition established after study to be chiefly responsible for occasioning the patient's admission.
A physician documents 'acute respiratory failure due to COPD exacerbation.' Which sequencing approach is correct for an inpatient admission?
Answer: Either condition may be sequenced first per coding guidelines
ICD-10-CM guidelines allow either acute respiratory failure or the underlying condition to be sequenced as the principal diagnosis when both are present at admission.
Which ICD-10-PCS approach value represents an endoscopic procedure performed entirely through an orifice without incision?
Answer: 8 – Via Natural or Artificial Opening Endoscopic
Approach value '8' in ICD-10-PCS represents procedures performed via natural or artificial opening using endoscopic visualization.
A patient with end-stage renal disease (ESRD) on hemodialysis develops hyperkalemia. The CDIS should query whether which additional condition may be clinically supported?
Answer: Electrolyte and fluid balance disorder due to ESRD
Hyperkalemia in ESRD patients is a common complication of impaired renal electrolyte regulation and may support documentation of an electrolyte/fluid disorder for complete code capture.