Certified Coding Associate Exam ICD-10-CM Coding Principles 1 — Questions and Answers
Question 1: In ICD-10-CM, what does the term 'principal diagnosis' mean for inpatient coding?
- The diagnosis present at the time of admission
- The condition established after study to be chiefly responsible for occasioning the admission (Correct answer)
- The patient's most chronic condition
- The first diagnosis listed by the physician
Correct answer: The condition established after study to be chiefly responsible for occasioning the admission
The principal diagnosis is the condition established after study to be chiefly responsible for occasioning the patient's admission to the hospital.
Question 2: What is the correct sequencing rule when a patient is admitted for chemotherapy?
- Sequence the malignancy as the principal diagnosis
- Sequence the encounter for chemotherapy (Z51.11) as the principal diagnosis (Correct answer)
- Sequence the metastatic site first
- Sequence the primary symptom as the first-listed diagnosis
Correct answer: Sequence the encounter for chemotherapy (Z51.11) as the principal diagnosis
When a patient is admitted for chemotherapy administration, Z51.11 is sequenced as the principal diagnosis, followed by the malignancy code.
Question 3: What does the ICD-10-CM instruction 'Code first' indicate?
- Always list this code as a secondary diagnosis
- A mandatory sequencing instruction requiring an underlying condition be coded first (Correct answer)
- This code may be sequenced in any order
- Use this code only for outpatient encounters
Correct answer: A mandatory sequencing instruction requiring an underlying condition be coded first
The 'Code first' instruction is a mandatory sequencing note that requires the underlying condition or etiology to be sequenced before the manifestation code.
Question 4: Which of the following is a valid ICD-10-CM code format?
- A12.345
- K21.0 (Correct answer)
- 4567
- AB.12
Correct answer: K21.0
ICD-10-CM codes begin with a letter, followed by two digits, a decimal point, and up to four additional characters (e.g., K21.0).
Question 5: In ICD-10-CM, what does the placeholder character 'X' indicate?
- The code is invalid and should not be used
- A dummy placeholder used to allow for future expansion or to fill a required position (Correct answer)
- The condition is unknown
- The code applies to male patients only
Correct answer: A dummy placeholder used to allow for future expansion or to fill a required position
The placeholder character 'X' is used in ICD-10-CM to allow for future expansion and to fill positions when additional characters are required.
Question 6: What does the 7th character 'A' represent in ICD-10-CM injury codes?
- Subsequent encounter
- Initial encounter (Correct answer)
- Sequela
- Acute phase
Correct answer: Initial encounter
The 7th character 'A' in ICD-10-CM injury codes denotes the initial encounter, meaning the patient is receiving active treatment for the injury.
Certified Coding Associate Exam ICD-10-CM Coding Principles 1
In ICD-10-CM, what does the term 'principal diagnosis' mean for inpatient coding?