Certified Coding Associate Exam ICD-10-CM Coding Principles 2 — Questions and Answers
Question 1: According to ICD-10-CM Official Guidelines, how should a 'probable' diagnosis be coded in the inpatient setting?
- Code only the signs and symptoms
- Code the condition as if confirmed (Correct answer)
- Do not assign a code until confirmed
- Add a Z code to indicate uncertainty
Correct answer: Code the condition as if confirmed
In the inpatient setting, conditions described as 'probable,' 'suspected,' or 'likely' should be coded as if confirmed per the Official Guidelines.
Question 2: In ICD-10-CM, what is a 'combination code'?
- Two separate codes used together
- A single code that classifies both an etiology and a manifestation, or a disease with an associated complication (Correct answer)
- A code that combines outpatient and inpatient data
- A code that applies to multiple age groups
Correct answer: A single code that classifies both an etiology and a manifestation, or a disease with an associated complication
A combination code is a single ICD-10-CM code that captures both an etiology and its associated manifestation, or a disease with a common complication.
Question 3: How should hypertension be coded in ICD-10-CM when no causal relationship is documented?
- As secondary hypertension
- As essential (primary) hypertension with code I10 (Correct answer)
- As hypertensive crisis
- As a symptom code only
Correct answer: As essential (primary) hypertension with code I10
When hypertension is documented without a specified cause, it is coded as essential (primary) hypertension using I10.
Question 4: Which of the following represents the correct use of an 'Excludes1' note in ICD-10-CM?
- The excluded code may be used together with this code if the patient has both conditions
- The two codes cannot be used together because they represent the same condition (Correct answer)
- The excluded code is required as an additional code
- The excluded condition should be sequenced first
Correct answer: The two codes cannot be used together because they represent the same condition
An 'Excludes1' note means the two codes represent the same condition and cannot be reported together; they are mutually exclusive.
Question 5: When coding acute and chronic conditions in ICD-10-CM, which sequencing rule applies if separate codes exist?
- Code the chronic condition first
- Code the acute condition first (Correct answer)
- Use only one code for the condition
- Code based on physician preference
Correct answer: Code the acute condition first
Per ICD-10-CM guidelines, when separate codes exist for acute and chronic conditions, the acute code is sequenced first.
Question 6: In ICD-10-CM, what do Z codes primarily represent?
- Injuries and trauma
- Factors influencing health status and encounters not due to illness or injury (Correct answer)
- Mental health disorders
- Infectious diseases
Correct answer: Factors influencing health status and encounters not due to illness or injury
Z codes represent factors that influence health status or reasons for healthcare encounters that are not due to a current illness or injury.
Certified Coding Associate Exam ICD-10-CM Coding Principles 2
According to ICD-10-CM Official Guidelines, how should a 'probable' diagnosis be coded in the inpatient setting?