CPC ICD-10-CM Diagnosis Coding 3 — Questions and Answers
Question 1: In ICD-10-CM, external cause codes (V, W, X, Y codes) are used to:
- Identify the principal diagnosis for injuries
- Describe how an injury or health condition occurred (Correct answer)
- Replace the injury diagnosis code
- Report hospital-acquired conditions only
Correct answer: Describe how an injury or health condition occurred
External cause codes describe how and where an injury occurred and are reported in addition to the injury code.
Question 2: When coding an obstetric case, the default assumption about the trimester should be:
- First trimester if unspecified
- The trimester documented in the medical record (Correct answer)
- Third trimester if the patient is near term
- The trimester is not required for obstetric coding
Correct answer: The trimester documented in the medical record
The trimester should be coded based on documentation in the medical record; coders should not assume a trimester.
Question 3: Which type of code is used to indicate that a patient has a personal history of a condition that no longer exists?
- Active diagnosis code
- Z code (personal history) (Correct answer)
- Sequela code
- Symptom code
Correct answer: Z code (personal history)
Z codes for personal history (e.g., Z85–Z87) indicate that a patient had a condition in the past that no longer exists but may affect current care.
Question 4: The guideline 'Code to the highest degree of certainty' applies primarily to which care setting?
- Inpatient hospital
- Outpatient and physician office (Correct answer)
- Long-term care
- Emergency department only
Correct answer: Outpatient and physician office
For outpatient/physician office visits, coders must code to the highest degree of certainty documented, without coding unconfirmed diagnoses.
Question 5: A patient is admitted due to dehydration caused by chemotherapy. Which condition is sequenced first?
- The malignancy
- The dehydration (Correct answer)
- The adverse effect of the chemotherapy drug
- The underlying cancer site
Correct answer: The dehydration
When admission is due to a complication such as dehydration, that complication is sequenced as the principal diagnosis.
Question 6: What is the correct approach when coding an encounter for chemotherapy for a malignancy?
- Sequence the malignancy first
- Sequence the encounter for chemotherapy (Z51.11) first (Correct answer)
- Code only the malignancy
- Code the adverse effect of the drug first
Correct answer: Sequence the encounter for chemotherapy (Z51.11) first
When the purpose of the encounter is chemotherapy, Z51.11 is sequenced first followed by the malignancy code.
CPC ICD-10-CM Diagnosis Coding 3
In ICD-10-CM, external cause codes (V, W, X, Y codes) are used to: