Certified Coding Associate Exam Certified Coding Associate Clinical 2

Question 1

A patient is admitted with acute respiratory failure due to pneumonia. Which condition should be sequenced as the principal diagnosis?

Accepted Answer

Either may be sequenced first per UHDDS

Answer

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)?

Accepted Answer

Z68

Answer

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?

Accepted Answer

Percutaneous endoscopic

Answer

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?

Accepted Answer

Not allowed — code signs and symptoms instead

Answer

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?

Accepted Answer

N18.6 and Z99.2

Answer

Both N18.6 (end-stage renal disease) and Z99.2 (dependence on renal dialysis) are assigned when a patient has ESRD on dialysis.

Certified Coding Associate Exam Practice Test