Case Studies & Practical Application Flashcards
7 cards from real Certified Medical Coding Specialist practice questions. Tap to flip, then mark Knew It or Still Learning — missed cards come back until you master them.
Read the first 7 Case Studies & Practical Application flashcards as text
A patient with type 2 diabetes presents with a diabetic foot ulcer on the right heel. The documentation states the ulcer is limited to the skin. Which ICD-10-CM code set is most appropriate?
Answer: E11.621, L97.419
E11.621 captures type 2 diabetes with foot ulcer, and L97.419 identifies the right heel ulcer limited to the skin with unspecified severity.
During an office visit, a physician documents 'patient seen for follow-up of hypertension and is also complaining of knee pain.' How many diagnoses should be coded?
Answer: Two — hypertension and the knee pain
Both conditions were addressed during the encounter, so both hypertension and knee pain should be coded per ICD-10-CM guidelines.
A surgical note documents removal of a 2.1 cm benign skin lesion from the back with simple closure. Which CPT code range applies?
Answer: 11400–11406
CPT codes 11400–11406 cover excision of benign lesions on the trunk, including the back, based on lesion diameter.
An inpatient record lists pneumonia as the principal diagnosis with a secondary diagnosis of COPD exacerbation. Under UHDDS guidelines, which condition is the principal diagnosis?
Answer: Pneumonia because it was the reason for admission after study
The principal diagnosis is the condition established after study to be chiefly responsible for causing the admission, which is pneumonia in this case.
A patient undergoes arthroscopic partial medial meniscectomy of the left knee. Which CPT code is appropriate?
Answer: 29881
CPT 29881 describes arthroscopy of the knee with meniscectomy (medial or lateral), which is the correct code for this procedure.
A coder notices the operative report documents a cholecystectomy, but the discharge summary only mentions 'abdominal surgery.' What is the correct coding action?
Answer: Code the cholecystectomy from the operative report
Operative reports are the primary source for procedure coding; the cholecystectomy documented there should be coded.
A patient is admitted for a hip fracture sustained from a fall at home. The secondary diagnosis includes osteoporosis. How should these be sequenced?
Answer: Use the combination code for age-related osteoporosis with hip fracture
ICD-10-CM provides a combination code (M80) for age-related osteoporosis with current pathological fracture, which captures both conditions in one code.