Clinical Coding Flashcards
7 cards from real CDIP 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
A patient undergoes a laparoscopic cholecystectomy converted to open due to adhesions. How should this be coded in ICD-10-CM/PCS?
Answer: Code only the open cholecystectomy
Per ICD-10-PCS guidelines, when a laparoscopic procedure is converted to open, only the open procedure is coded.
Which condition is NOT reportable as an additional diagnosis under UHDDS guidelines?
Answer: A condition that existed prior to admission but had no effect on care
UHDDS defines additional diagnoses as those requiring clinical evaluation, therapeutic treatment, diagnostic procedures, extended stay, or increased nursing care; conditions with no effect on current care are not reported.
When a provider documents 'possible' or 'probable' diagnosis at discharge in an inpatient setting, how should it be coded?
Answer: Code the uncertain diagnosis as if confirmed
For inpatient coding, ICD-10-CM guidelines allow coding of conditions documented as 'possible,' 'probable,' or 'suspected' as if established at the time of discharge.
A patient with Type 2 diabetes is admitted for hyperglycemic hyperosmolar state (HHS). Which is the correct principal diagnosis code?
Answer: E11.00 – Type 2 DM with hyperosmolarity without NKHHC
HHS without coma in a Type 2 diabetic is coded E11.00, which specifically captures hyperosmolarity without nonketotic hyperglycemic-hyperosmolar coma.
In CPT, modifier -51 (multiple procedures) is appended to indicate what?
Answer: Additional procedures performed at the same session beyond the primary
Modifier -51 is used to report multiple procedures performed at the same session by the same provider, applied to the secondary procedures.
Which MS-DRG component is most directly impacted by the documentation and coding of a Major Complication or Comorbidity (MCC)?
Answer: DRG relative weight and reimbursement tier
Capturing an MCC elevates the DRG to its highest-severity tier, directly increasing the relative weight and associated reimbursement.
When coding a patient with both COPD and acute exacerbation of asthma, what is the correct ICD-10-CM approach?
Answer: Code asthma with acute exacerbation and COPD separately
ICD-10-CM instructs coders to assign separate codes for COPD and asthma when both are documented, including the acute exacerbation code for asthma.