CCS Medical Coding Guidelines & Compliance 2

Question 1

According to the ICD-10-CM Official Guidelines, what is the definition of the principal diagnosis for inpatient coding?

Accepted Answer

The condition established after study to be chiefly responsible for occasioning the admission

Answer

Per UHDDS and ICD-10-CM Guidelines, the principal diagnosis is 'the condition established after study to be chiefly responsible for occasioning the admission to the hospital for care.'

Question 2

Under ICD-10-CM Official Coding Guidelines, when two or more diagnoses meet the definition of principal diagnosis, how should the coder proceed?

Accepted Answer

Either condition may be sequenced first

Answer

When two or more conditions equally meet the definition of principal diagnosis, the Official Guidelines state that either may be sequenced first as principal diagnosis.

Question 3

What is the ICD-10-CM coding guideline for signs and symptoms that are integral to a confirmed disease?

Accepted Answer

Do not code signs and symptoms routinely reported with the confirmed disease

Answer

Per ICD-10-CM Guidelines, signs and symptoms that are routinely associated with a disease process (integral to the disease) should not be assigned as additional codes.

Question 4

Under the ICD-10-CM Official Guidelines, the term 'code also' means:

Accepted Answer

An additional code should be reported if applicable and present

Answer

'Code also' is an instructional note indicating that an additional code may be assigned if the condition is present and applicable - it is not always mandatory.

Question 5

A patient is treated for a fractured femur resulting from a fall from a ladder at a construction site. In addition to the fracture code, what additional code type is required by ICD-10-CM?

Accepted Answer

An external cause code (V00-Y99) for the mechanism and place of injury

Answer

ICD-10-CM Guidelines require external cause codes (Chapter 20, V00-Y99) to capture the mechanism of injury (fall from ladder) and place of occurrence (construction site) when injuries are coded.

(CCS) Certified Coding Specialist Practice Test

(CCS) Certified Coding Specialist Practice Test

CCS Medical Coding Guidelines & Compliance 2