CDIP Clinical Coding 3

Question 1

A patient undergoes a laparoscopic cholecystectomy converted to open due to adhesions. How should this be coded in ICD-10-CM/PCS?

Accepted Answer

Code only the open cholecystectomy

Answer

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?

Accepted Answer

A condition that existed prior to admission but had no effect on care

Answer

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?

Accepted Answer

Code the uncertain diagnosis as if confirmed

Answer

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?

Accepted Answer

E11.00 – Type 2 DM with hyperosmolarity without NKHHC

Answer

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?

Accepted Answer

Additional procedures performed at the same session beyond the primary

Answer

Modifier -51 is used to report multiple procedures performed at the same session by the same provider, applied to the secondary procedures.

(CDIP) Certified Documentation Improvement Practitioner Practice Test

(CDIP) Certified Documentation Improvement Practitioner Practice Test

CDIP Clinical Coding 3