Clinical Coding Flashcards
7 cards from real CCDS practice questions. Tap to flip, then mark Knew It or Still Learning — missed cards come back until you master them.
Read the first 7 Clinical Coding flashcards as text
A patient is admitted with acute-on-chronic systolic heart failure and hypertensive heart disease. Which ICD-10-CM code set correctly captures this combination?
Answer: I13.0 and I50.21
ICD-10-CM code I13.0 combines hypertensive heart disease with heart failure, and I50.21 specifies the acute-on-chronic systolic type, per combination code guidelines.
Under ICD-10-PCS, which character position represents the body part in a Medical and Surgical section procedure?
Answer: Character 4
In ICD-10-PCS Medical and Surgical section, character 4 represents the body part involved in the procedure.
A coder encounters a diagnosis of 'probable pneumonia' documented by the attending physician on an inpatient record. How should this be coded?
Answer: Code the pneumonia as confirmed
For inpatient records, UHDDS guidelines allow coding of conditions documented as 'probable' or 'suspected' as if confirmed.
Which MS-DRG grouping concept refers to a secondary diagnosis that increases the severity of illness and resource use, elevating DRG assignment?
Answer: Complication or Comorbidity (CC)
A Complication or Comorbidity (CC) or Major CC (MCC) is a secondary diagnosis that increases DRG weight and reimbursement under the IPPS system.
A patient undergoes a right total knee arthroplasty. The ICD-10-PCS root operation that best describes replacing the knee joint with a synthetic substitute is:
Answer: Replacement
ICD-10-PCS defines 'Replacement' as putting in or on biological or synthetic material that physically takes the place of a body part.
When a patient is admitted for chemotherapy and also has the malignancy being treated, which condition should be sequenced as the principal diagnosis?
Answer: The chemotherapy encounter (Z51.11)
Per ICD-10-CM guidelines, when admission is for chemotherapy, Z51.11 (encounter for antineoplastic chemotherapy) is sequenced as the principal diagnosis.
A CDIS reviews a record where the physician documents 'MRSA bacteremia.' Which ICD-10-CM coding approach is correct?
Answer: Code B95.62 as an additional code to A41.02
A41.02 captures MRSA septicemia/bacteremia; however, B95.62 is assigned as an additional code when MRSA is the causative agent in a condition classified elsewhere.