CCS CCS ICD-10-CM Diagnosis Coding 2 — Questions and Answers
Question 1: A combination code in ICD-10-CM is best described as:
- Two codes used together to fully describe a condition
- A single code that classifies two diagnoses, a diagnosis with an associated complication, or a diagnosis with an associated manifestation (Correct answer)
- A code used only for inpatient settings
- A code requiring a 7th character extension
Correct answer: A single code that classifies two diagnoses, a diagnosis with an associated complication, or a diagnosis with an associated manifestation
A combination code captures two related conditions in a single code, avoiding the need for multiple codes when one fully describes the situation.
Question 2: Which of the following Z code categories is used to indicate a patient's history of a resolved condition that no longer exists but may affect future care?
- Z00-Z13 (Encounters for examinations)
- Z77-Z99 (Persons with potential health hazards)
- Z80-Z84 (Family history)
- Z85-Z87 (Personal history) (Correct answer)
Correct answer: Z85-Z87 (Personal history)
Z85-Z87 personal history codes document past conditions that have been resolved but may influence current or future medical management.
Question 3: In ICD-10-CM, 'laterality' refers to:
- The severity level of a diagnosis
- Specifying which side of the body (right, left, bilateral) is affected (Correct answer)
- The encounter type for bilateral procedures
- A code extension used for pediatric conditions
Correct answer: Specifying which side of the body (right, left, bilateral) is affected
Laterality codes in ICD-10-CM identify the specific side of the body involved when a condition is site-specific.
Question 4: An 'Excludes2' note in ICD-10-CM indicates:
- The excluded condition can never be coded with the code containing the note
- The excluded condition is not part of the indexed condition but may occur simultaneously and both may be coded (Correct answer)
- The code is deleted from the classification
- The condition has been reclassified to a different chapter
Correct answer: The excluded condition is not part of the indexed condition but may occur simultaneously and both may be coded
An Excludes2 note means the excluded condition is distinct from the indexed condition and, if both are present, both may be coded.
Question 5: When coding signs and symptoms in ICD-10-CM for an outpatient visit, the coder should:
- Always code the suspected diagnosis instead of signs and symptoms
- Code signs and symptoms when no definitive diagnosis has been established (Correct answer)
- Never code signs and symptoms if a chronic disease is also present
- Code signs and symptoms only for inpatient encounters
Correct answer: Code signs and symptoms when no definitive diagnosis has been established
For outpatient encounters, signs and symptoms are coded when the physician has not established a definitive diagnosis.
Question 6: The 'principal diagnosis' for an inpatient encounter is defined as:
- The diagnosis present on admission
- The condition established after study to be chiefly responsible for occasioning the admission (Correct answer)
- The most resource-intensive condition treated
- The first diagnosis listed in the medical record
Correct answer: The condition established after study to be chiefly responsible for occasioning the admission
The principal diagnosis is determined after workup and defined as the condition chiefly responsible for the patient's admission to the hospital.
CCS CCS ICD-10-CM Diagnosis Coding 2
A combination code in ICD-10-CM is best described as: