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 physician documents 'SIRS due to non-infectious process (pancreatitis).' Which ICD-10-CM code is assigned for the SIRS?
Answer: R65.10 – SIRS of non-infectious origin without acute organ dysfunction
SIRS due to a non-infectious process is coded R65.10 (without organ dysfunction) or R65.11 (with organ dysfunction), not as sepsis.
Which ICD-10-CM guideline governs coding of conditions that are integral to a disease process?
Answer: Signs and symptoms that are integral to the disease process should NOT be coded separately
Per ICD-10-CM guidelines, signs and symptoms that are routine and integral to a confirmed disease process are not assigned additional codes.
A patient is admitted for a hip fracture and develops a stage 3 pressure ulcer of the heel during the inpatient stay. What POA indicator is assigned to the pressure ulcer?
Answer: N – Not present at admission
A pressure ulcer that develops during the inpatient stay was not present at the time of admission and receives POA indicator 'N.'
Under ICD-10-CM, malnutrition documented in a hospitalized patient is best supported by which clinical indicator for CDI purposes?
Answer: Low prealbumin or albumin levels with reduced oral intake and weight loss
Malnutrition is supported by objective findings such as low prealbumin/albumin, reduced intake, and unintentional weight loss rather than a single marker.
When a patient has an acute-on-chronic condition, such as acute-on-chronic systolic heart failure, how is it coded in ICD-10-CM?
Answer: Use the combination code that captures both acute and chronic
ICD-10-CM provides combination codes (e.g., I50.21) that capture both the acute and chronic components of heart failure in a single code.
In ICD-10-PCS, which root operation is used when a device is put in without cutting or puncturing the skin or mucous membrane?
Answer: Introduction
The root operation 'Introduction' is defined as putting in or on a therapeutic, diagnostic, nutritional, physiological, or prophylactic substance except blood or blood products.
A coder assigns a code for 'hypertensive heart disease with heart failure.' Which ICD-10-CM guideline supports presuming a causal relationship?
Answer: Hypertension guideline presuming a causal relationship between hypertension and heart failure
ICD-10-CM guidelines instruct coders to presume a causal relationship between hypertension and heart failure, assigning codes from category I11.