CDIP Clinical Coding 4

Question 1

A physician documents 'SIRS due to non-infectious process (pancreatitis).' Which ICD-10-CM code is assigned for the SIRS?

Accepted Answer

R65.10 – SIRS of non-infectious origin without acute organ dysfunction

Answer

SIRS due to a non-infectious process is coded R65.10 (without organ dysfunction) or R65.11 (with organ dysfunction), not as sepsis.

Question 2

Which ICD-10-CM guideline governs coding of conditions that are integral to a disease process?

Accepted Answer

Signs and symptoms that are integral to the disease process should NOT be coded separately

Answer

Per ICD-10-CM guidelines, signs and symptoms that are routine and integral to a confirmed disease process are not assigned additional codes.

Question 3

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?

Accepted Answer

N – Not present at admission

Answer

A pressure ulcer that develops during the inpatient stay was not present at the time of admission and receives POA indicator 'N.'

Question 4

Under ICD-10-CM, malnutrition documented in a hospitalized patient is best supported by which clinical indicator for CDI purposes?

Accepted Answer

Low prealbumin or albumin levels with reduced oral intake and weight loss

Answer

Malnutrition is supported by objective findings such as low prealbumin/albumin, reduced intake, and unintentional weight loss rather than a single marker.

Question 5

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?

Accepted Answer

Use the combination code that captures both acute and chronic

Answer

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.

(CDIP) Certified Documentation Improvement Practitioner Practice Test

(CDIP) Certified Documentation Improvement Practitioner Practice Test

CDIP Clinical Coding 4