CCDS Clinical Coding 2

Question 1

Under ICD-10-PCS, which of the seven characters defines the specific approach used for a procedure?

Accepted Answer

Character 5 (Approach)

Answer

In ICD-10-PCS, Character 5 specifies the approach used to reach the operative site, such as open, percutaneous, endoscopic, or via natural or artificial opening.

Question 2

A patient undergoes a laparoscopic cholecystectomy that is converted to an open procedure. How should this be coded in ICD-10-PCS?

Accepted Answer

Code only the open approach since it was the completed procedure

Answer

Per ICD-10-PCS guidelines, when a procedure is converted from a laparoscopic to an open approach, only the open approach procedure code is assigned. The laparoscopic portion that did not complete the intended procedure is not separately coded.

Question 3

Which ICD-10-CM code category is used to report sepsis due to a gram-positive organism when the specific organism is identified?

Accepted Answer

A41 - Other sepsis

Answer

Category A41 (Other sepsis) covers sepsis due to specific organisms including Staphylococcus aureus. The specific organism code from A40-A41 is sequenced first, followed by R65.2x if severe sepsis criteria are met.

Question 4

What is the ICD-10-CM convention for coding a condition that is integral to a disease process?

Accepted Answer

It is not coded separately, as it is inherent to the condition

Answer

ICD-10-CM Guideline Section I.B.5 states that signs and symptoms that are integral to a disease process should not be assigned as additional codes unless otherwise instructed by the classification.

Question 5

A patient is admitted with acute respiratory failure due to pneumonia. Which is the correct sequencing under ICD-10-CM inpatient guidelines?

Accepted Answer

Either condition may be sequenced as principal diagnosis per coding guideline discretion

Answer

ICD-10-CM guideline I.C.10.b states that when both respiratory failure and another condition such as pneumonia are equally responsible for the admission, either may be sequenced as the principal diagnosis.

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CCDS Clinical Coding 2