CPC ICD-10-CM Diagnosis Coding 2 — Questions and Answers
Question 1: According to ICD-10-CM guidelines, when should signs and symptoms be coded in addition to a confirmed diagnosis?
- Always, for every outpatient encounter
- When the sign or symptom is not routinely associated with the confirmed diagnosis (Correct answer)
- Only when the physician documents both the sign and the diagnosis separately
- Only for inpatient admissions
Correct answer: When the sign or symptom is not routinely associated with the confirmed diagnosis
Signs and symptoms that are NOT integral to (routinely associated with) a confirmed diagnosis should be coded as additional codes.
Question 2: What does a 'Code First' instruction in ICD-10-CM direct the coder to do?
- Always list this code as the principal diagnosis regardless of circumstances
- Sequence the underlying etiology before the manifestation code (Correct answer)
- Use this code before any Z-code on the claim
- Assign this code as the first secondary diagnosis
Correct answer: Sequence the underlying etiology before the manifestation code
A 'Code First' note instructs the coder to sequence the underlying condition (etiology) before the manifestation code, following the etiology/manifestation convention.
Question 3: What is a combination code in ICD-10-CM?
- A code that links two unrelated diagnoses on the same claim
- A single code that classifies two diagnoses, a diagnosis with a complication, or a diagnosis with an associated manifestation (Correct answer)
- A code used only when two chronic conditions coexist
- A code that combines a diagnosis with a CPT procedure code
Correct answer: A single code that classifies two diagnoses, a diagnosis with a complication, or a diagnosis with an associated manifestation
A combination code is one code that captures multiple clinical concepts simultaneously, such as a condition and its associated complication or manifestation.
Question 4: What does an 'Excludes1' note in ICD-10-CM indicate?
- The excluded condition may be coded elsewhere in the classification
- The two conditions cannot coexist, so both codes should never be reported together (Correct answer)
- The excluded code should always be listed second
- The condition is included within the current code
Correct answer: The two conditions cannot coexist, so both codes should never be reported together
An Excludes1 note is a 'pure' exclusion meaning the two conditions are mutually exclusive and can never be coded together for the same patient at the same time.
Question 5: What does an 'Excludes2' note in ICD-10-CM mean?
- The excluded condition is completely forbidden from use with this code
- The excluded condition is not included here, but both conditions may coexist and be coded simultaneously (Correct answer)
- Only one of the two conditions may be coded per encounter
- The excluded code must be sequenced after this code
Correct answer: The excluded condition is not included here, but both conditions may coexist and be coded simultaneously
An Excludes2 note means the excluded condition is not included in the current code, but a patient may have both conditions at the same time, in which case both codes may be assigned.
Question 6: When is it appropriate to use an unspecified ICD-10-CM code?
- Never — coders must always query the physician for additional detail
- When the medical record lacks sufficient information to assign a more specific code (Correct answer)
- Only as a secondary diagnosis, never as the principal diagnosis
- Only when the condition is still being worked up and no diagnosis is confirmed
Correct answer: When the medical record lacks sufficient information to assign a more specific code
Unspecified codes are valid when the medical record documentation genuinely does not support assignment of a more specific code.
Question 7: ICD-10-CM Z codes are primarily used to represent:
- Symptoms without a definitive diagnosis
- External causes of morbidity and injury
- Factors influencing health status and reasons for encounters not due to illness or injury (Correct answer)
- Neoplasm diagnoses and tumor staging
Correct answer: Factors influencing health status and reasons for encounters not due to illness or injury
Z codes capture reasons for encounters such as preventive screenings, immunizations, history of conditions, and other factors affecting health status that are not diseases or injuries.
CPC ICD-10-CM Diagnosis Coding 2
According to ICD-10-CM guidelines, when should signs and symptoms be coded in addition to a confirmed diagnosis?