CDIP Clinical Coding 3 — Questions and Answers
Question 1: A patient undergoes a laparoscopic cholecystectomy converted to open due to adhesions. How should this be coded in ICD-10-CM/PCS?
- Code only the open cholecystectomy (Correct answer)
- Code only the laparoscopic cholecystectomy
- Code both the laparoscopic attempt and the open cholecystectomy
- Code the laparoscopic with a conversion qualifier
Correct 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.
Question 2: Which condition is NOT reportable as an additional diagnosis under UHDDS guidelines?
- A condition that required additional nursing monitoring
- A condition that caused the admission
- A condition that existed prior to admission but had no effect on care (Correct answer)
- A chronic condition actively managed during the stay
Correct 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.
Question 3: When a provider documents 'possible' or 'probable' diagnosis at discharge in an inpatient setting, how should it be coded?
- Code the signs and symptoms, not the uncertain diagnosis
- Code the uncertain diagnosis as if confirmed (Correct answer)
- Assign a code for 'suspected' condition from Z03 category
- Do not code it; query the physician for confirmation
Correct 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.
Question 4: A patient with Type 2 diabetes is admitted for hyperglycemic hyperosmolar state (HHS). Which is the correct principal diagnosis code?
- E11.65 – Type 2 DM with hyperglycemia
- E11.00 – Type 2 DM with hyperosmolarity without NKHHC (Correct answer)
- E11.01 – Type 2 DM with hyperosmolarity with coma
- R73.09 – Other abnormal glucose
Correct 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.
Question 5: In CPT, modifier -51 (multiple procedures) is appended to indicate what?
- A procedure performed by a second surgeon
- Additional procedures performed at the same session beyond the primary (Correct answer)
- A procedure repeated on a different day
- Bilateral procedures performed simultaneously
Correct 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.
Question 6: Which MS-DRG component is most directly impacted by the documentation and coding of a Major Complication or Comorbidity (MCC)?
- Base DRG assignment
- DRG relative weight and reimbursement tier (Correct answer)
- Length of stay threshold only
- Discharge disposition coding
Correct 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.
Question 7: When coding a patient with both COPD and acute exacerbation of asthma, what is the correct ICD-10-CM approach?
- Code only the COPD; asthma is included
- Code asthma with acute exacerbation and COPD separately (Correct answer)
- Use J44.1 for COPD with acute exacerbation to cover both
- Code only the condition requiring the most resources
Correct 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.
CDIP Clinical Coding 3
A patient undergoes a laparoscopic cholecystectomy converted to open due to adhesions.
How should this be coded in ICD-10-CM/PCS?