Diagnosis Coding

CCS-P · 76 questions

• A county family clinic sees a patient for uncontrolled type 2 diabetes with documented diabetic nephropathy. The assessment links nephropathy as a manifestation of the diabetes. How should the coder approach diagnosis assignment for this physician claim?
• A community health center documents acute bronchitis as the reason for today's visit. The problem list also lists stable hypertension that was not assessed, treated, or managed during this encounter. What is the correct first-listed diagnosis approach for the outpatient claim?
• A pediatric clinic note states 'rule out appendicitis' after an abdominal pain workup, and no confirmed diagnosis is established by the close of the visit. How should diagnoses be reported for this physician-office claim?
• An orthopedics group documents a closed fracture of the left distal radius, initial encounter for closed treatment in the clinic. Which episode-of-care concept should guide the seventh-character family for this physician claim?
• A pulmonology clinic treats an acute exacerbation of COPD and also documents tobacco dependence that is addressed with counseling during the same visit. What diagnosis coding approach is most appropriate?
• A dermatology note describes malignant melanoma of the left upper arm excised today. History of breast cancer is mentioned as past and not under treatment. How should the malignancies be distinguished on the physician claim?
• An OB/GYN office documents supervision of a normal first pregnancy at 28 weeks with no complications. Which coding concept best guides ambulatory obstetric diagnosis selection?
• A behavioral health clinic documents major depressive disorder, recurrent, moderate, and the provider actively manages medications. What is the correct specificity approach?
• A sports medicine visit documents a sprain of the right ankle, subsequent encounter for routine healing. Which concepts must be reflected in diagnosis coding?
• An infectious disease clinic confirms COVID-19 by laboratory testing and treats pneumonia documented as due to COVID-19. What sequencing concept applies for this ambulatory physician claim?
• A gastroenterology note lists GERD with esophagitis clearly documented. Which diagnosis coding judgment is correct?
• A nephrology visit documents stage 4 chronic kidney disease with underlying type 2 diabetes. What coding concept should the physician-office coder apply?
• An allergy clinic documents anaphylaxis due to peanut ingestion, initial encounter. Which coding approach best reflects the documented food-induced anaphylaxis concept?
• A primary-care follow-up addresses a healing surgical wound infection after an appendectomy performed weeks ago at a hospital. What should the physician-office coder report?
• A cardiology clinic documents hypertensive heart disease with heart failure, and both are treated. Which diagnosis approach is correct?
• An ENT visit is for chronic bilateral otitis media with effusion. What specificity judgment should guide diagnosis coding?
• A rheumatology note documents rheumatoid arthritis of multiple sites with rheumatoid factor positive. How should the coder apply specificity?
• A urology clinic treats benign prostatic hyperplasia with lower urinary tract symptoms documented and linked to the BPH. What is the preferred coding judgment?
• An oncology infusion suite in a physician practice documents an encounter for antineoplastic chemotherapy with primary breast cancer still under treatment. Which diagnosis concept pairing is appropriate?
• A pain clinic documents chronic pain syndrome. The note is not describing expected acute postoperative pain after a recent procedure. How should the coder distinguish these concepts?
• A school-based clinic documents a pediatric BMI percentile and provides obesity counseling based on that measure and clinical assessment. When may BMI/pediatric BMI coding be reported?
• A travel clinic documents an encounter for vaccinations with no illness present. What diagnosis coding concept applies?
• An urgent-care physician group visit documents dehydration due to viral gastroenteritis. How should etiology and dehydration be captured?
• A neurology clinic documents migraine with aura, intractable, without status migrainosus. What specificity approach is required?
• A wound-care clinic documents a pressure ulcer of the sacrum, stage 3. Which coding requirement applies?
• An endocrinology office visit documents hypothyroidism due to Hashimoto thyroiditis. How should diagnosis coding specificity be approached for the professional claim?
• A primary-care note documents homelessness as a social determinant affecting care, and the provider addresses housing resources during the visit. When is an SDOH Z-code appropriate on the professional claim?
• An ophthalmology visit documents primary open-angle glaucoma, bilateral, moderate stage. Which coding approach best reflects ICD-10-CM specificity expectations?
• A hematology clinic documents iron-deficiency anemia due to chronic blood loss. What diagnosis coding choice best matches the documentation?
• A family practice documents a depression screening that is positive, and the same-day assessment establishes a new diagnosis of depression. How should ICD-10-CM reporting generally be handled?
• A surgical specialty office documents follow-up for sequela of a traumatic brain injury with residual cognitive deficit. Which concept should guide diagnosis coding?
• An allergy clinic note documents a rash as an adverse effect of a correctly prescribed antibiotic taken as directed. Which drug-effect coding family applies?
• A cardiology follow-up documents coronary artery bypass graft (CABG) status without acute ischemic symptoms. What coding approach is appropriate?
• An emergency-department follow-up in the physician’s clinic documents concussion without loss of consciousness as a subsequent encounter. Which elements must coding reflect?
• A multi-specialty group codes a well-child visit at which abnormal findings are identified and evaluated. How should the routine child health examination diagnosis concept be selected?
• A pulmonology note documents asthma, mild persistent, with acute exacerbation. What should diagnosis coding capture?
• A gastroenterology clinic documents Crohn’s disease of the large intestine with fistula. Which specificity approach is correct?
• A county clinic documents exposure to tuberculosis with negative testing and counseling for chemoprophylaxis. How should this differ from active TB disease coding?
• While assigning ICD-10-CM for a clinic encounter, a coder sees an Excludes1 note between two closely related conditions in the Tabular List. What does Excludes1 generally mean for code assignment?
• Clinic documentation supports both a condition with a “Code first” etiology instruction and its manifestation. How should sequencing be approached?
• A clinic note states only “UTI” with no organism or further site detail. What is the appropriate coding response under ICD-10-CM conventions?
• A fracture note in an orthopedic clinic omits laterality that the ICD-10-CM classification requires. What should the coder do?
• An injury code structure in ICD-10-CM uses placeholder “X” characters. What is the purpose of those placeholders?
• A provider’s note says “history of asthma,” but the assessment shows active asthma treatment during today’s clinic visit. How should coding distinguish history versus active disease?
• Two conditions are linked by “with” in the ICD-10-CM Alphabetic Index for a physician-office encounter. What convention generally applies?
• An Excludes2 note appears between a symptom code and a definitive diagnosis category in the Tabular List. What does Excludes2 indicate for physician coding?
• An outpatient assessment lists “probable pneumonia.” Applying outpatient uncertain-diagnosis guidelines, what should the physician-office coder do?
• A clinic note documents both BMI and obesity. Under ICD-10-CM guideline relationships, when may BMI be reported?
• A diabetic patient has neuropathy documented in a specialty clinic note without the exact phrase “diabetic neuropathy,” but Index and “with” conventions may link diabetes and neuropathy. What coding judgment applies?
• Seventh-character options for a pathologic fracture differ by encounter type in an orthopedic follow-up. How should the coder choose between initial and subsequent characters?
• A family practice coder reviews a visit for hypertensive chronic kidney disease. Documentation fully supports a combination code that identifies both conditions. What is the correct coding approach?
• An occupational medicine note documents current nicotine dependence. The social history also mentions past smoking and occasional ‘tobacco use.’ Which nicotine status concept should drive code selection?
• An OB/GYN clinic note for a pregnant patient documents completed weeks of gestation required by the obstetric chapter. How should the physician-office coder handle gestational timing?
• A dermatology pathology report describes a neoplasm of uncertain behavior. The assessment does not use ‘unspecified behavior’ language. Which neoplasm-table concept applies?
• An occupational medicine visit documents a work-related injury with a clear mechanism of how the injury occurred. What is the appropriate role of external-cause coding on the physician claim?
• A walk-in clinic assessment states ‘SIRS due to pneumonia’ and does not document sepsis. Nursing triage notes mention possible sepsis criteria. How should the coder proceed?
• A rheumatology note documents osteoarthritis of the right knee and left hip with enough detail for site-specific coding. A multiple-sites OA option also exists in the classification. What is the preferred approach?
• Documentation supports a fully specified ICD-10-CM diagnosis, but the coder stops at a truncated parent code that is not billable. What guideline concept is violated?
• An orthopedic clinic sees a patient for routine follow-up of a healing traumatic fracture after active treatment is complete. Which diagnosis concept applies?
• An endocrinology note documents hyperglycemia related to underdosing of insulin because the patient could not afford the medication. Which coding approach best reflects the documentation?
• A neurology office note documents an NIH Stroke Scale score along with a residual neurologic diagnosis after prior CVA. How should the scale information be treated for diagnosis coding?
• A burn clinic documents partial-thickness burns with a stated extent of body surface involved. Which coding concept should guide diagnosis assignment?
• An infectious disease clinic documents symptomatic HIV disease currently being treated. Which HIV status coding concept applies?
• A wound clinic documents a skin infection and identifies a causative organism, and the classification instructs an additional code for the organism. What should the coder do?
• A primary-care preventive visit documents that the patient’s mother had breast cancer; the patient has no personal history of malignancy. Which history concept is correct?
• A pulmonology urgent visit documents acute on chronic respiratory failure. Which coding approach is correct?
• A clinic note states ‘borderline diabetes’ without a confirmed diabetes mellitus diagnosis. How should the coder handle this language?
• A coder locates a tentative ICD-10-CM code in the Alphabetic Index for a clinic diagnosis. What mandatory next step applies before final assignment?
• An oncology clinic documents secondary malignancy in bone. The primary site was previously excised and is documented only as history, with no current primary disease. How should primary versus history be reflected?
• A behavioral health assessment documents social anxiety disorder. Which diagnosis specificity approach is correct?
• A neurology clinic follow-up documents hemiplegia as a sequela of prior CVA, including affected side and dominance when known. What coding concept applies?
• A culture report in an infectious disease clinic documents an infection with a drug-resistant organism. How should resistance status be handled?
• In the ICD-10-CM Alphabetic Index, a main term includes nonessential modifiers in parentheses. The clinic note does not include those parenthetical words. What is the correct interpretation?
• An Alphabetic Index subterm after a colon lists essential modifiers for a clinic diagnosis pathway. Documentation lacks those required terms. What should the coder do?
• An ICD-10-CM code title uses the word ‘and’ between two conditions. How should a physician-office coder interpret ‘and’ in code titles under ICD-10-CM conventions?
• A county clinic note documents both acute and chronic sinusitis during the same encounter, and the ICD-10-CM chapter for that condition provides combination and sequencing guidance. How should the physician-based coder approach code assignment?