ICD-10-CM Post-Discussion Tests

What are NEC and NOS considered in the ICD-10-CM code book?

Abbreviations

What are the parties responsible for providing the ICD-10-CM guidelines?

NCHS and CMS

What type of code is assigned when the provider documents the reason for a patient seeking healthcare services is not for an injury or disease?

Z code (Z00-Z99)

In the ICD-10-CM Alphabetic Index, what is the code next to the main term called?

Default Code

What does ICD-10-CM stand for?

International Classification of Diseases 10th Revision, Clinical Modification

Which section of the ICD-10-CM guidelines contains instructions on how to code for a patient receiving diagnostic services only in an outpatient setting?

Section IV

Which of the following is an example of an eponym?

Paget’s disease

The terms "malignant", "benign", "in situ", and "uncertain behavior" are used when coding what?

Neoplasms

What is the meaning of "provider" in the ICD-10-CM guidelines?

The physician

In which month does the new ICD-10-CM code book take effect each year?

October

What does ICD-10-CM guideline I.B.1 state to use when locating and assigning a diagnosis code?

ICD-10-CM Alphabetic Index and Tabular List

Which of the following statements is true in reference to reporting body mass index (BMI) codes?

BMI codes should be reported as a secondary code only.

What do the instructions and conventions of the classification take precedence over?

Official Coding Guidelines

How should the word "and" be interpreted in the ICD-10-CM when it appears in a title?

“And” or “or” – patient may have either or both

When a patient has a condition that is both acute and chronic and there are separate Alphabetic Index entries for each acuity at the same indentation level, how is it reported?

Code both sequencing the acute code first

A 6-year-old patient is seen in the office for acute otitis media, coded as H66.90. This is an example of which ICD-10-CM convention?

NOS

The diagnosis caudal cervical inflammatory spondylopathy is assigned ICD-10-CM code M46.82 and is an example of which ICD-10-CM coding convention?

NEC

According to the Tabular List in the ICD-10-CM code book, category H80, Otosclerosis, includes what other disorder?

Otospongiosis

Which of the following diagnosis code/s report/s pain in the left and right ears?

H92.03

According to the Tabular List, which of the following codes contains an instructional note that indicates that two related conditions cannot occur together?

N94.2

According to the Alphabetic Index, which of the following main terms has an instructional note indicating another main term may also be referenced that may provide additional Alphabetic Index entries that may be useful?

Fibrosarcoma

In the Alphabetic Index, there are parenthetical terms next to the main term "hypertension, hypertensive". What do these parenthetical terms indicate?

Supplementary words that can be present or absent with the diagnosis of hypertension and does not affect the code to which it is assigned.

What is the sequencing order when coding a sequela (late effect)?

The residual condition is coded first, and the code(s) for the cause of the late effect are coded as secondary.

Which diagnosis code/s should be reported for chronic gonococcal salpingitis?

A54.24

Which of the following is a combination code?

K80.00

What do brackets indicate in the Alphabetic Index?

Use the code/s in brackets in addition to the disease or condition to identity an associated manifestation.

In locating a code in the ICD-10-CM code book, where must one begin searching for a main term?

The Alphabetic Index

The maximum number of characters a code may contain is _______.

Seven

This is the character that the ICD-10-CM uses as a placeholder to allow for the classification's future expansion.

X

Which of the following statements is true about assigning multiple codes?

Signs and symptoms that are routinely associated with a disease process are not reported separately.

The following are examples of signs and symptoms EXCEPT for:

Adenocarcinoma

The following are examples of a diagnosis EXCEPT for:

Epistaxis

Which of the following follows the required level of detail in coding in the ICD-10-CM?

G47.11

According to the use-additional-code note under G72.1, Alcoholic myopathy, from which category should you select the additional code if applicable?

F10

Which of the following codes may be reported along with codes under category E21?

E83.52

This is the condition produced after the acute phase of an illness or injury has terminated.

Sequela

The following are examples of combination codes EXCEPT:

D68.51

The code for accidental arsenic poisoning requires how many characters?

Seven

This is a case of a newborn female with sepsis due to Mycoplasma pneumoniae. Which ICD-10-CM codes are assigned?

P36.8, B96.0

Which of the following statements is true about coding conditions with laterality?

If a bilateral condition has no bilateral code, two codes are assigned, one for the left side and one for the right side

A _______ is a single code that is used to classify two diagnoses.

Combination code

The patient is a 78-year-old male who came in for a left senile cortical cataract extraction and intraocular lens implant. He is status post right cataract extraction from a previous admission and is recovering nicely without any more evidence of the disease. The procedure was done. The patient's postoperative course was uneventful. How should the cataract be coded?

H25.012

The following pieces of information may be obtained from documentation by clinicians other than the patient's provider EXCEPT:

Pressure Ulcer Site

The following conditions are included under code D68.2 EXCEPT for:

Consumption coagulopathy

A borderline diagnosis at the time of discharge is coded as confirmed if:

The condition has no specific "borderline" entry in the Alphabetic Index

How is impending delirium tremens coded?

F10.239

Which external cause codes take sequencing priority over all other external cause codes except for child and adult abuse and terrorism?

Codes for cataclysmic events

What does the acronym CAPS stand for in coding external causes of injury?

Cause, Activity, Place, and Status

According to the ICD-10-CM guidelines, how is a syndrome coded in the absence of an Alphabetic Index guidance?

Assign codes for the documented manifestations of the syndrome.

The following statements are true about external causes of morbidity EXCEPT:

All of the above statements are true.

Which of the following is the correct code assignment for rheumatoid juvenile arthritis of multiple sites?

M08.09

Which of the following Z-codes best describes a patient who is currently living in an abandoned building?

Z59.02

Can Z codes be sequenced as a primary/first-listed diagnosis?

Yes, Z codes may be sequenced as either a primary/first-listed code or as secondary codes.

Mr. Smith presents to the office for a screening test to detect sickle cell disorder. Which ICD-10-CM code/s is/are reported?

Z13.0

A 2-month-old is seeing his pediatrician for a routine health check examination. The physician notices a diaper rash and prescribes an ointment to treat it. Which ICD-10-CM code/s is/are reported?

Z00.121, L22

The patient is in the facility today for a screening colonoscopy. During the procedure, a polyp is found and removed with a hot biopsy technique. How would this be reported?

Z12.11, K63.5

A 6-month-old patient is seen at the clinic for a routine well-child visit and vaccinations. During the examination, the provider finds that the child has a fever, and a diagnosis of acute otitis media in the right ear is documented. Vaccinations are not given at this time. Which ICD-10-CM code/s is/are reported?

Z00.121, H66.91, Z28.01

A 12-month-old receives the following vaccinations: Hepatitis B, Hib, Varicella, and Mumps-measles-rubella. Which ICD-10-CM code/s is/are reported for the vaccinations?

Z23

A male patient is here for chemotherapy for his metastatic carcinoma of the liver secondary to cancer of the right areola. Which ICD-10-CM codes are reported?

Z51.11, C78.7, C50.021

The patient is admitted for radiation therapy for his metastatic bone cancer, unknown primary. She develops severe vomiting secondary to the radiation. Which ICD-10-CM code/s is/are reported?

Z51.0, C79.51, C80.1, R11.10

Which of the following ICD-10-CM codes is used to indicate long-term use of a direct oral anticoagulant for anticoagulation therapy?

Z79.01

Beginning 2025, how is a personal history of non-neoplastic polyps coded?

Z86.0100

Which ICD-10-CM code describes a screening for diabetes?

Z13.1

An 82-year-old patient presented for cardiac resynchronization therapy device (CRT-D) generator change due to an elective replacement indicator (ERI). Prior to admission, the left ventricular (LV) lead had been turned off due to an LV lead malfunction found during a prior CRT-D interrogation. During this admission, the patient, together with his family, decided against having an implantable cardioverter-defibrillator procedure. The CRT-D generator was removed, and a dual chamber permanent pacemaker (PPM) generator was implanted. The right atrial and ventricular leads were found to be in satisfactory condition and were used with the new device. The left ventricular lead was found to be fractured and was capped. What is the appropriate ICD-10-CM code for this admission?

Z45.02

An adult male patient presents to the hospital emergency department for possible exposure to the rabies virus. A bat got into his house and, after capturing it and freeing it, he noticed some scratches on his arms. He has never received a rabies vaccine before. The physician begins the post-exposure prophylactic treatment with human rabies immune globulin and a rabies vaccination administered intramuscularly. What is the ICD-10-CM coding for this initial encounter?

Z23, Z29.14, Z20.3, W55.89XA

Which of the following statements is true about external causes of morbidity?

An external cause code may be used with any code in the range of A00.0-T88.9 and Z00-Z99.

Which external cause code/s is/are reported for a passenger involved in an MVA that lost control on the interstate highway and hit a guardrail?

V47.6XXA, Y92.411

A patient is admitted to surgery to treat an open fracture of the shaft of the right humerus and a simple closed fracture of the left tibia following an ATV accident. Which ICD-10-CM codes are reported for this case?

S42.301B, S82.202A, V86.95XA

A 4-year-old is brought into the ED crying. He cannot bend his left arm after his older sister pulled it. The ED provider performs an X-ray, and it shows that the patient has Nursemaid’s elbow. The provider reduces the elbow successfully. The patient can move his arm again after the reduction. Which ICD-10-CM codes are assigned for this encounter?

S53.032A, X50.9XXA

A 60-year-old patient sustained a comminuted left calcaneal fracture after falling from a ladder. Initial ED treatment consisted of diagnostic radiology studies, and surgical ORIF was performed 9 days later. The patient now presents to the orthopedic clinic for evaluation and cast change. The fracture is healing normally. Which ICD-10-CM code/s is/are assigned?

S92.002D, W11.XXXD

This 14-year-old male patient is brought to the ED after falling from his skateboard at a public park. Imaging reveals a displaced transverse fracture of the right femoral shaft with multiple significant abrasions of the right thigh. Which ICD-10-CM codes are reported for this scenario?

S72.321A, V00.131A, Y93.51, Y92.830

A 7-year-old female patient was seen in the emergency department after being bitten by a dog. The child received treatment for the puncture wounds to her left leg. She also received a rabies vaccine because the dog was known to have rabies. Which ICD-10-CM codes are reported?

S81.852A, Z20.3, Z23, W54.0XXA

A 16-year-old male is brought to the ED by his mother. He was riding his bicycle in the park when he hit a bump and fell off. The patient's right arm is painful to touch, discolored, and swollen. The X-ray reveals a closed fracture of the ulna. Which ICD-10-CM codes are reported?

S52.201A, V18.0XXA, Y92.830

A 47-year-old male was treated in the ED after being involved in a fight at a local bar. The patient sustained two lacerations, one to the left cheek and one to the left forearm. Abrasions were also noted on the left cheek. Which ICD-10-CM codes are assigned for this case?

S01.412A, S51.812A, Y04.0XXA, Y92.59

The patient is a 19-year-old male who presents with nasal pain, swelling, and mild epistaxis after being hit in the face by a football. He was playing tackle football with his friends earlier today at the university football field. He denies loss of consciousness, vision changes, or difficulty breathing. X-ray reveals a displaced nasal fracture. Which ICD-10-CM codes best describe this scenario?

S02.2XXA, W21.01XA, Y93.61, Y92.321

The patient is a 26-year-old female brought to the emergency department by EMS after intentionally ingesting an unknown quantity of her zolpidem approximately one hour prior to arrival. The ingestion occurred in her bedroom at her apartment. The patient admits the ingestion was intentional and states she was feeling overwhelmed. She denies co-ingestion of alcohol or other substances. Her past medical history is significant for clinical depression, for which she is also evaluated during this encounter. Final diagnoses are: Intentional poisoning with zolpidem and major depressive disorder. Which ICD-10-CM codes are reported?

T42.6X2A, F32.9, Y92.032

The patient is a 42-year-old male construction worker who presents to the emergency department after falling approximately 8 feet from a ladder at a construction site earlier today. The patient reports the ladder slipped while he was installing drywall on the second floor. He landed on his right arm and lower back. He denies loss of consciousness but reports immediate pain and swelling in the right wrist and pain in the lumbar region. Injury occurred while performing job duties. X-rays reveal a right distal radial fracture and a normal lumbar spine. Closed reduction of the radial fracture is performed successfully. Which ICD-10-CM codes are reported for this case?

S52.501A, W11.XXXA, Y93.H3, Y92.69, Y99.0

The patient is a 29-year-old female who presents to an urgent care clinic after walking and slipping on a wet public sidewalk earlier today. The patient reports losing her footing and falling forward, landing on her left knee and left hand. She denies loss of consciousness, head injury, or dizziness. Pain is mild to moderate and worsens with walking. No prior treatment was attempted. X-ray of the left knee reveals no fracture or dislocation. Final diagnoses are: Left knee contusion and abrasion of the left hand. The wound is cleaned and dressed, and ice is applied to the left knee. OTC pain meds are recommended. Which ICD-10-CM codes appropriately describe this scenario?

S80.02XA, S60.512A, W01.0XXA, Y93.01, Y92.480

What does the abbreviation CKD stand for?

Chronic Kidney Disease

What does the root word colp/o mean?

Vagina

The provider documents CKD stage 5 and ESRD. Which ICD-10-CM code/s is/are reported?

N18.6

A 45-year-old mother of three children is having surgery to correct an anterior vaginal wall prolapse with an incomplete uterine prolapse. How is this case coded?

N81.2

A patient has benign prostatic hyperplasia with urinary retention. Which ICD-10-CM code/s is/are reported?

N40.1, R33.8

A woman with a long history of rectocele has perineal scarring from multiple episiotomies and has developed a rectovaginal fistula with perineal body relaxation. She has transperineal repair with perineal body reconstruction and plication of the levator muscles to correct these conditions. Which ICD-10-CM codes are reported?

N82.3, N90.89

Acute tubular necrosis is the most common cause of acute renal failure and is the second most common cause of all types of acute renal failure in hospitalized adults. Prerenal azotemia is the most common type of ATN. How is ATN coded in the ICD-10-CM?

N17.0

The patient is admitted in fluid overload from missed dialysis sessions for ESRD. The discharge summary states the fluid overload is due to the missed dialysis sessions. What is the correct principal diagnosis for this scenario?

E87.70

What is the ICD-10-CM code for Peyronie's disease?

N48.6

A patient is documented to have hypertension, end-stage renal disease, and diastolic congestive heart failure. The patient receives dialysis. How is this coded?

I13.2, N18.6, I50.30, Z99.2

A patient with hypertension, stage 2 chronic kidney disease, and heart failure presents to her medical provider for a check-up. The provider documents that the patient's hypertension is not related to her chronic kidney disease or heart failure. How is this coded?

I10, N18.2, I50.9

A patient is diagnosed with steroid-dependent minimal change disease and nephrotic syndrome. What are the correct code assignments for these conditions?

N04.0, Z79.52

A 60-year-old female is diagnosed with acute kidney injury due to acute tubular necrosis secondary to contrast nephropathy. What is the appropriate code assignment for this case?

N17.0, N14.11, T50.8X5A

A patient returns to the provider for an injection to relieve low back pain from a car accident. Which ICD-10-CM code/s is/are reported?

M54.50

What is the time frame defining when pain becomes chronic?

No time frame

A 32-year-old patient with an ophthalmoplegic migraine is not responding to medication and is admitted to the observation unit. Which ICD-10-CM code is reported?

G43.B1

Mrs. Johnson is here today to receive an intercostal nerve block to mitigate the debilitating pain of her malignancy. Her cancer has metastasized to her bones in her thoracic spine. Which ICD-10-CM codes are reported?

G89.3, C79.51, C80.1

A young male is brought to the clinic by his mom. He has had periods of major depression for many years and is on lithium. His provider also manages his migraine headaches and epilepsy. During the past week, he has become increasingly psychotic. He has been hearing voices, telling him to kill himself, and having intense feelings of worthlessness. On the day of the clinic visit, he has had an epileptic seizure that could not be controlled by medication. He is admitted for lithium adjustment. Final diagnoses are: Severe depression with psychotic behavior and epileptic seizure, poorly controlled with medication. Which ICD-10-CM codes should be reported?

F33.3, G40.919

A 58-year-old patient sees the provider for confusion and loss of memory. The provider diagnoses the patient with early-onset Alzheimer’s disease with dementia. Which ICD-10-CM codes are reported?

G30.0, F02.80

A 32-year-old patient presents to the emergency department with complaints of lethargy and is admitted and diagnosed with sepsis due to a urinary tract infection. The patient is also diagnosed with metabolic encephalopathy due to the sepsis and toxic encephalopathy secondary to pain medication that was properly administered. Which of the following ICD-10-CM diagnosis codes should be assigned for metabolic encephalopathy and toxic encephalopathy?

G92.8, Other toxic encephalopathy and G93.41, Metabolic encephalopathy

A patient presents to the emergency department due to a decreased level of consciousness and fever. The patient's condition worsens with the development of acute encephalopathy, acute lactic acidosis, and rhabdomyolysis. The patient is admitted to the ICU and, following workup, is diagnosed with acute drug-induced encephalopathy due to serotonin syndrome from an adverse effect of sertraline. What is the appropriate code assignment for this admission?

G90.81, T43.225A, G92.8, M62.82, E87.21

The patient previously suffered an anterior dislocation of the left hip, which was reduced. However, this was followed by numbness and weakness in the left femoral nerve distribution. Evaluation indicated that she would benefit from surgery. A left femoral nerve external (percutaneous) neurolysis was carried out successfully. Discharge diagnosis: Mononeuritis, femoral nerve. How is this encounter coded?

G57.22, S73.035S