Certified Medical Coding Specialist Case Studies & Practical Application 2 — Questions and Answers
Question 1: 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?
- E11.621, L97.419 (Correct answer)
- E11.65, L97.419
- E11.40, L97.519
- E11.621, L97.519
Correct 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.
Question 2: 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?
- One — only the primary reason for visit
- Two — hypertension and the knee pain (Correct answer)
- Two — only if the knee pain changes the management
- One — only the knee pain as it is a new complaint
Correct 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.
Question 3: A surgical note documents removal of a 2.1 cm benign skin lesion from the back with simple closure. Which CPT code range applies?
- 11400–11406 (Correct answer)
- 11600–11606
- 11420–11426
- 11440–11446
Correct answer: 11400–11406
CPT codes 11400–11406 cover excision of benign lesions on the trunk, including the back, based on lesion diameter.
Question 4: 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?
- COPD exacerbation because it is a chronic condition
- Pneumonia because it was the reason for admission after study (Correct answer)
- The condition requiring the most resources
- The condition listed first by the physician
Correct 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.
Question 5: A patient undergoes arthroscopic partial medial meniscectomy of the left knee. Which CPT code is appropriate?
- 27332
- 29881 (Correct answer)
- 27347
- 29880
Correct answer: 29881
CPT 29881 describes arthroscopy of the knee with meniscectomy (medial or lateral), which is the correct code for this procedure.
Question 6: A coder notices the operative report documents a cholecystectomy, but the discharge summary only mentions 'abdominal surgery.' What is the correct coding action?
- Code 'abdominal surgery' as documented in the discharge summary
- Query the physician to reconcile the discrepancy
- Code the cholecystectomy from the operative report (Correct answer)
- Assign the most specific code from either document
Correct answer: Code the cholecystectomy from the operative report
Operative reports are the primary source for procedure coding; the cholecystectomy documented there should be coded.
Question 7: A patient is admitted for a hip fracture sustained from a fall at home. The secondary diagnosis includes osteoporosis. How should these be sequenced?
- Osteoporosis first, then the fracture
- Fracture first, then osteoporosis as a comorbidity
- Use the combination code for age-related osteoporosis with hip fracture (Correct answer)
- Only code the fracture; osteoporosis is implied
Correct 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.
Certified Medical Coding Specialist Case Studies & Practical Application 2
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?