CCDS Clinical Coding 4

Question 1

A patient is admitted with acute-on-chronic systolic heart failure and hypertensive heart disease. Which ICD-10-CM code set correctly captures this combination?

Accepted Answer

I13.0 and I50.21

Answer

ICD-10-CM code I13.0 combines hypertensive heart disease with heart failure, and I50.21 specifies the acute-on-chronic systolic type, per combination code guidelines.

Question 2

Under ICD-10-PCS, which character position represents the body part in a Medical and Surgical section procedure?

Accepted Answer

Character 4

Answer

In ICD-10-PCS Medical and Surgical section, character 4 represents the body part involved in the procedure.

Question 3

A coder encounters a diagnosis of 'probable pneumonia' documented by the attending physician on an inpatient record. How should this be coded?

Accepted Answer

Code the pneumonia as confirmed

Answer

For inpatient records, UHDDS guidelines allow coding of conditions documented as 'probable' or 'suspected' as if confirmed.

Question 4

Which MS-DRG grouping concept refers to a secondary diagnosis that increases the severity of illness and resource use, elevating DRG assignment?

Accepted Answer

Complication or Comorbidity (CC)

Answer

A Complication or Comorbidity (CC) or Major CC (MCC) is a secondary diagnosis that increases DRG weight and reimbursement under the IPPS system.

Question 5

A patient undergoes a right total knee arthroplasty. The ICD-10-PCS root operation that best describes replacing the knee joint with a synthetic substitute is:

Accepted Answer

Replacement

Answer

ICD-10-PCS defines 'Replacement' as putting in or on biological or synthetic material that physically takes the place of a body part.

CCDS - Certified Clinical Documentation Specialist Practice Test

CCDS - Certified Clinical Documentation Specialist Practice Test

CCDS Clinical Coding 4