CDIP Clinical Coding 2

Question 1

When a patient is admitted with a condition that is not the principal diagnosis but requires clinical documentation improvement, which coding guideline applies to selecting the principal diagnosis?

Accepted Answer

Select the condition chiefly responsible for the stay after study

Answer

Use the condition that caused the admission as principal diagnosis

Answer

Code the most resource-intensive condition as principal

Answer

Always use the attending physician's listed first diagnosis

Question 2

A patient with sepsis due to a urinary tract infection is admitted. Under ICD-10-CM, which sequencing is correct?

Accepted Answer

Sepsis first, then UTI as the underlying infection

Answer

UTI first, then sepsis

Answer

Either order is acceptable per ICD-10-CM

Answer

Code only sepsis; UTI is included

Question 3

Which ICD-10-CM code category is used to report chronic kidney disease (CKD) complicating a condition such as diabetes mellitus?

Accepted Answer

E11.x with N18.x as combination codes

Answer

N18.x with an external cause code

Answer

N18.x only, diabetes is captured in HCC

Answer

Z99.2 for dependence on renal dialysis

Question 4

A CDI specialist queries the physician about 'acute blood loss anemia' found in clinical indicators. The physician confirms. How should this be coded?

Accepted Answer

D62 (acute posthemorrhagic anemia)

Answer

D64.9 (unspecified anemia)

Answer

D50.0 (iron deficiency anemia secondary to blood loss)

Answer

Z13.0 (encounter for screening for anemia)

Question 5

In CPT coding, what distinguishes a 'repair' from a 'reconstruction' when coding soft tissue procedures?

Accepted Answer

Repair uses local tissue; reconstruction uses distant or free flaps

Answer

Repair is coded with E/M codes; reconstruction with surgical codes

Answer

Repair applies to wounds under 5 cm; reconstruction to larger wounds

Answer

Reconstruction always requires an implant; repair does not

Question 6

Which Present on Admission (POA) indicator is used when the condition develops during an outpatient encounter and is present at inpatient admission?

Accepted Answer

Y – Present at admission

Answer

N – Not present at admission

Answer

W – Clinically undetermined

Answer

U – Documentation insufficient

Question 7

When coding pressure ulcers in ICD-10-CM, what two factors must be documented to assign the most specific code?

Accepted Answer

Stage and anatomic site

Answer

Stage and laterality

Answer

Size and depth of tissue involvement

Answer

Anatomic site and laterality