CCDS Clinical Coding 5

Question 1

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?

Accepted Answer

Use combination code E11.22 for diabetic CKD

Answer

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.

Question 2

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?

Accepted Answer

U

Answer

POA indicator 'U' is assigned when documentation is insufficient to determine if the condition was present on admission.

Question 3

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?

Accepted Answer

W11.XXXA

Answer

W11.XXXA represents a fall on and from a ladder, initial encounter, which correctly captures the external cause mechanism.

Question 4

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?

Accepted Answer

Occasioning the admission to the hospital

Answer

UHDDS defines the principal diagnosis as the condition established after study to be chiefly responsible for occasioning the patient's admission.

Question 5

A physician documents 'acute respiratory failure due to COPD exacerbation.' Which sequencing approach is correct for an inpatient admission?

Accepted Answer

Either condition may be sequenced first per coding guidelines

Answer

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.

CCDS - Certified Clinical Documentation Specialist Practice Test

CCDS - Certified Clinical Documentation Specialist Practice Test

CCDS Clinical Coding 5