ICD 10 Practical Applications 5

Question 1

A patient had breast cancer excised two years ago, has no evidence of disease, and receives no treatment. How is this reported?

Accepted Answer

Z85.3

Answer

When the primary malignancy has been excised or eradicated with no further treatment and no evidence of disease, a personal history Z85 code is used.

Question 2

A patient presents only to receive an influenza vaccination. Which code is first-listed?

Accepted Answer

Z23

Answer

Z23 is encounter for immunization, reported with the appropriate procedure code for the vaccine.

Question 3

A stage 3 pressure ulcer of the sacral region is documented. Which code is correct?

Accepted Answer

L89.153

Answer

L89.153 is pressure ulcer of sacral region, stage 3 (the last digit indicates stage).

Question 4

A dietitian documents a BMI of 38, and the physician documents obesity. Can the BMI code be reported?

Accepted Answer

Yes, BMI may come from other clinicians but the associated diagnosis must be provider-documented

Answer

BMI can be taken from clinicians other than the provider, but the associated diagnosis such as obesity must be documented by the provider.

Question 5

At inpatient discharge, the attending documents 'suspected pneumonia' and it remains uncertain. How does a hospital coder report it?

Accepted Answer

Code it as if it existed

Answer

For inpatient admissions to short-term acute care hospitals, uncertain diagnoses at discharge are coded as if established.

ICD 10 Practice Test