CDIP Clinical Coding 2 — Questions and Answers
Question 1: When a patient is admitted with a condition that is not the principal diagnosis but requires clinical documentation improvement, which coding guideline applies to selecting the principal diagnosis?
- Use the condition that caused the admission as principal diagnosis
- Select the condition chiefly responsible for the stay after study (Correct answer)
- Code the most resource-intensive condition as principal
- Always use the attending physician's listed first diagnosis
Correct answer: Select the condition chiefly responsible for the stay after study
The UHDDS definition states the principal diagnosis is the condition established after study to be chiefly responsible for causing the hospital admission.
Question 2: A patient with sepsis due to a urinary tract infection is admitted. Under ICD-10-CM, which sequencing is correct?
- UTI first, then sepsis
- Sepsis first, then UTI as the underlying infection (Correct answer)
- Either order is acceptable per ICD-10-CM
- Code only sepsis; UTI is included
Correct answer: Sepsis first, then UTI as the underlying infection
ICD-10-CM guidelines require sepsis to be sequenced first, followed by the code for the underlying localized infection such as UTI.
Question 3: Which ICD-10-CM code category is used to report chronic kidney disease (CKD) complicating a condition such as diabetes mellitus?
- N18.x with an external cause code
- E11.x with N18.x as combination codes (Correct answer)
- N18.x only, diabetes is captured in HCC
- Z99.2 for dependence on renal dialysis
Correct answer: E11.x with N18.x as combination codes
ICD-10-CM provides combination codes under E11.x (Type 2 DM with diabetic CKD) that capture both conditions together.
Question 4: A CDI specialist queries the physician about 'acute blood loss anemia' found in clinical indicators. The physician confirms. How should this be coded?
- D64.9 (unspecified anemia)
- D62 (acute posthemorrhagic anemia) (Correct answer)
- D50.0 (iron deficiency anemia secondary to blood loss)
- Z13.0 (encounter for screening for anemia)
Correct answer: D62 (acute posthemorrhagic anemia)
Acute blood loss anemia is specifically indexed to D62, acute posthemorrhagic anemia, in ICD-10-CM.
Question 5: In CPT coding, what distinguishes a 'repair' from a 'reconstruction' when coding soft tissue procedures?
- Repair uses local tissue; reconstruction uses distant or free flaps (Correct answer)
- Repair is coded with E/M codes; reconstruction with surgical codes
- Repair applies to wounds under 5 cm; reconstruction to larger wounds
- Reconstruction always requires an implant; repair does not
Correct answer: Repair uses local tissue; reconstruction uses distant or free flaps
CPT differentiates repair (direct closure or local tissue rearrangement) from reconstruction (tissue transfer from a distant site or free flap).
Question 6: Which Present on Admission (POA) indicator is used when the condition develops during an outpatient encounter and is present at inpatient admission?
- N – Not present at admission
- Y – Present at admission (Correct answer)
- W – Clinically undetermined
- U – Documentation insufficient
Correct answer: Y – Present at admission
If a condition developed during an outpatient encounter prior to the inpatient admission, it is considered present at admission and receives a 'Y' indicator.
Question 7: When coding pressure ulcers in ICD-10-CM, what two factors must be documented to assign the most specific code?
- Stage and laterality
- Stage and anatomic site (Correct answer)
- Size and depth of tissue involvement
- Anatomic site and laterality
Correct answer: Stage and anatomic site
ICD-10-CM requires both the anatomic site (e.g., sacrum, heel) and the stage (1–4, unstageable, deep tissue injury) to assign the most specific pressure ulcer code.
CDIP Clinical Coding 2
When a patient is admitted with a condition that is not the principal diagnosis but requires clinical documentation improvement, which coding guideline applies to selecting the principal diagnosis?