Certified Coding Associate Exam Certified Coding Associate Clinical 2 — Questions and Answers
Question 1: A patient is admitted with acute respiratory failure due to pneumonia. Which condition should be sequenced as the principal diagnosis?
- Acute respiratory failure
- Pneumonia
- Either may be sequenced first per UHDDS (Correct answer)
- The condition present on admission
Correct answer: Either may be sequenced first per UHDDS
When two conditions equally meet the UHDDS definition of principal diagnosis, either may be sequenced first.
Question 2: Which ICD-10-CM code category is used to report body mass index (BMI)?
- Z68 (Correct answer)
- E66
- R73
- Z17
Correct answer: Z68
BMI codes are found in category Z68 and are used as secondary codes when a provider documents obesity.
Question 3: A patient undergoes a laparoscopic cholecystectomy. In ICD-10-PCS, what value represents the laparoscopic approach?
- Open
- Percutaneous endoscopic (Correct answer)
- Percutaneous
- External
Correct answer: Percutaneous endoscopic
Laparoscopic procedures use the percutaneous endoscopic approach in ICD-10-PCS.
Question 4: Which term describes coding a condition that the physician has documented as 'possible' or 'probable' in the outpatient setting?
- Confirmed coding
- Uncertain diagnosis coding
- Not allowed — code signs and symptoms instead (Correct answer)
- Allowed only with attending approval
Correct answer: Not allowed — code signs and symptoms instead
For outpatient/ED encounters, uncertain diagnoses (possible, probable, suspected) are NOT coded; instead, code the signs, symptoms, or findings.
Question 5: A coder sees the note 'ESRD on dialysis.' Which code(s) should be assigned?
- N18.6 only
- N18.6 and Z99.2 (Correct answer)
- Z99.2 only
- N18.5 and Z99.2
Correct answer: N18.6 and Z99.2
Both N18.6 (end-stage renal disease) and Z99.2 (dependence on renal dialysis) are assigned when a patient has ESRD on dialysis.
Question 6: When a patient has a fracture coded to the seventh character 'D', what does this indicate?
- Initial encounter for fracture
- Subsequent encounter for fracture with routine healing (Correct answer)
- Sequela
- Delayed healing
Correct answer: Subsequent encounter for fracture with routine healing
The seventh character 'D' indicates a subsequent encounter for a fracture with routine healing.
Question 7: A patient is treated for sepsis due to Staphylococcus aureus. How should this be coded?
- A41.01 as principal diagnosis only (Correct answer)
- A41.01 for sepsis, then the organism code
- A41.9 followed by B95.61
- B95.61 followed by A41.01
Correct answer: A41.01 as principal diagnosis only
A41.01 (Sepsis due to Methicillin susceptible Staphylococcus aureus) fully captures both the sepsis and the organism in one combination code.
Certified Coding Associate Exam Certified Coding Associate Clinical 2
A patient is admitted with acute respiratory failure due to pneumonia.
Which condition should be sequenced as the principal diagnosis?