CPB Study Chapter 4
Patient who is HIV positive has been showing purplish nodules on the skin on different areas of the body. He is diagnosed with having Kaposi's sarcoma which is a manifestation of having AIDS. What ICD-10-CM code(s) is/are reported? A. B20, C46.0 B. C46.0, Z21 C. Z21 D. B20, C46.0, Z21
A. B20, C46.0 According to ICD-10-CM guidelines section I.C.1.2.d: Z21, Asymptomatic human immunodeficiency virus [HIV] infection, is to be applied when the patient without any documentation of symptoms is listed as being HIV positive, known HIV, HIV test positive, or similar terminology. Do not use this code if the term AIDS is used or if the patient is treated for any HIV-related illness or is described as having any condition(s) resulting from his/her HIV positive status; use B20 in these cases. In the question the patient is showing a condition (Kaposi's sarcoma) resulting from his HIV positive status, in which now code B20 (AIDS) will now be assigned. From the Alphabetic Index look for AIDS. You are referred to B20. There is a note in the Tabular List to use additional code(s) to identify all manifestations of HIV infection. Next, look for Kaposi's/sarcoma/skin (multiple sites). You are referred to C46.0. The scenario documented that this type of cancer was found on the skin of the patient.
Child is brought in by her mother for a skin rash on her arms, legs, and midsection. Mother states the patient has been playing in a field across from the house. She is diagnosed with chigger bites. What ICD-10-CM code is reported (do not code the External Cause)? A. B88.0 B. B88.9 C. B88.8 D. S40.869A
A. B88.0 Alphabetic index look-up of chiggers (infestation) leads to B88.0, other ascariasis. Ascariasis is defined as infestation with or disease caused by mites.
After testing a newborn in the NICU, the newborn is found to have hypothyroidism due to congenital absence of a thyroid gland. How is this reported for the newborn? A. E03.1 B. P72.2 C. E03.8 D. E03.4
A. E03.1 Congenital means present at birth. Although it seems like a code from the congenital anomaly chapter would apply to a congenital condition, not all congenital codes appear there. From the Alphabetic Index look for Hypothyroidism/congenital (without goiter). You are referred to E03.1. In the Tabular List under code E03.4 there is an excludes note that indicates Congenital atrophy of thyroid is excluded from E03.4; meaning you do not code E03.4 for congenital hypothyroidism. Because congenital hypothyroidism is classified to a specific code, a nonspecific alternative (E03.8) is not appropriate. This thyroid disorder is not transitory, since it is permanent, therefore code P72.2 is incorrect.
Which code set does a biller use to report diagnoses for a physician's office? A. ICD-10-CM B. ICD-10-PCS C. both ICD-10-CM and ICD-10-PCS D. CPT
A. ICD-10-CM ICD-10-PCS (Procedure Coding System) is used to report inpatient facility procedures. It is not used by physicians. ICD-10-CM (Clinical Modification) is used by all providers to indicate the reason a patient received services (the diagnosis).
What is/are the correct code(s) for a patient with acute on chronic maxillary sinusitis? A. J01.00, J32.0 B. J01.01 C. J01.01, J32.8 D. J32.0, J01.00
A. J01.00, J32.0 There are instances when a patient will have both the acute form and the chronic form of a condition and there is not a combination code to report both the acute and the chronic condition. In this case, the acute code is sequenced first followed by the code for the chronic condition. The provider does not state that the acute sinusitis is recurring, so J01.01 is incorrect.
OB patient at 36 weeks presents with mild headache, leg edema. Her UA shows protein. She is diagnosed with pre-eclampsia and admitted for observation. What ICD-10-CM code(s) is/are reported? A. O14.93, Z3A.36 B. R51, R60.9 C. O14.93 D. O14.13, Z3A.36
A. O14.93, Z3A.36 Chapter 15 Coding guidelines state that Chapter 15 codes have sequencing priority over codes from other chapters. In the Alphabetic Index, look for Pregnancy/ complicated by/ pre-eclampsia which leads to subcategory O14.9. The notes at the beginning of the chapter state that the 3rd trimester is 28 weeks until delivery, and to use an additional code from category Z3A, Weeks of gestation, to identify the specific week of the pregnancy. The 5th character 3 is used for the third trimester and code Z3A.36 indicates she is at 36 weeks.
What is the ICD-10-CM code for a cough? A. R05 B. F45.8 C. R04.2 D. J41.0
A. R05 In the Alphabetic Index, look for Cough. You are referred to R05. In the Tabular List locate and validate that R05 is the correct code for cough.
Which of the following is a table in ICD-10-CM? A. Table of Drugs and Chemicals B. Table of Causes of Injury C. Table of Burns D. Hypertension Table
A. Table of Drugs and Chemicals ICD-10-CM contains two tables with which the biller should be familiar: the Table of Drugs and Chemicals and the Neoplasm Table.
The patient's dense breast tissue made the screening mammogram unreadable, and she is here today for a breast ultrasound. Her mother and aunt both have a history of breast cancer. What ICD-10-CM codes are reported for breast ultrasound?: A. Z12.39, R92.2, Z80.3 B. Z12.39, R92.2, Z85.3 C. N63, Z80.3 D. N63, R92.2, Z85.3
A. Z12.39, R92.2, Z80.3 Code the special screening as a reason for the encounter, along with a code to report the patient's breast density, which provides medical necessity for a more extensive test. Dense breast tissue occurs in many premenopausal women, and can interfere with reading a mammogram and may mask abnormalities in the image. From the Alphabetic Index look for Screening/ neoplasm (malignant)/breast refers you to Z12.39. Next look for Dense/breast, refers you to R92.2. Finally look for History /family/malignant neoplasm/breast, refers you to Z80.3.
Patient presents with follow-up of Type 1 Diabetes with Stage 3 CKD. What code(s) is/are reported? A. E11.9, N18.3 B. E10.22, N18.3 C. E10.22 D. E11.22, N18.3
B. E10.22, N18.3 In the ICD-10-CM Alphabetic Index, look for Diabetes, diabetic (mellitus) (sugar)/type 1/with/chronic kidney disease, which refers the user toE10.22. In the Tabular List locate code E10.22. The note states to use an additional code to identify the stage of the CKD (N18.1-N18.6). Looking up those codes in the Tabular List shows that Stage 3 is coded as N18.3.
A 32-year-old has been admitted to a 45 day program for rehabilitation. She has a daily barbiturate dependence with anxiety disorder. What ICD-10-CM code(s) is/are reported? A. F13.10, F41.9 Correct is B B. F13.280 C. F41.9, F13.280 D. F13.980
B. F13.280 The key word is dependence. There is documentation that she has a drug dependence to the barbiturates. From the Alphabetic Index look for Dependence/barbiturates(s) which states to see Dependence, drug, sedative. Dependence/drug/sedative/with/anxiety disorder refers you to code F13.280.
What are the correct codes for a patient with type 1 diabetic CKD stage 3? A. E11.22, N18.3 B. N18.1, E10.22 C. E10.22, N18.1 D. E10.22, N18.3
D. E10.22, N18.3 Look in the Alphabetic Index for Diabetes/type 1/chronic kidney disease E10.22. Turn to this code in the Tabular List. There is a use additional code note under code E10.22 that states to code the stage of chronic kidney disease in addition to the diabetes. Reference codes N18.1-N18.6 in the Tabular List. The Stage 3 is coded with N18.3.
66-year-old fractured her scaphoid bone in her right wrist three months ago. She now presents with a nonunion of the scaphoid bone. What is the appropriate ICD-10-CM code? A. S62.001P B. S62.001G C. S62.001S D. S62.001K
D. S62.001K According to ICD-10-CM Guidelines Section I.C.19.c.1., Care of complications of fractures, such as malunion and nonunion, should be reported with the appropriate 7th character for subsequent care with nonunion (K, M, N,) or subsequent care with malunion (P, Q, R). From the Alphabetic Index, see Fracture/traumatic/scaphoid (hand) which says to see also Fracture/carpal/navicular, which in turn indexes to S62.00-. Looking up S62.00 in the Tabular List gives us a 6th character 1 for the right wrist. By reviewing the 7th character information box at the beginning of the category, you will see that the 7th character K is used for non-union. The final code then is S62.001K.
30-year-old female suffers from menstrual migraines. She is in the ED because the medication has not relieved the migraine. What ICD-10-CM code is reported? A. G43.829 B. G43.839 C. G43.919 D. G43.909
B. G43.839 From the Alphabetic Index look for Migraine/menstrual. This refers you to category G43. In the Tabular List, there is a note under the category that states "Note: the following terms are to be considered equivalent to intractable: pharmacoresistant (pharmacologically resistant), treatment resistant, refractory (medically) and poorly controlled." Therefore, since the migraine is not responding to medication, it is considered intractable. Further reference in the Tabular List shows the correct code to be G43.839.
A patient presents to the ophthalmologist for follow up of hypertensive retinopathy in both eyes. The physician determines the retinopathy is due to the patient's malignant hypertension. What ICD-10-CM code(s) is/are reported? A. I10, H35.033 B. H35.033, I10 C. H35.033 D. I10
B. H35.033, I10 From the Alphabetic Index look for, Retinopathy/hypertensive. This refers you to H35.03-. Look for this code in the Tabular List; a 6th character is necessary, in this case, 3 indicates bilateral. There is a note stating to code also any associated hypertension (I10.-). ICD-10-CM Guideline I.C.9.a.5 indicates for Hypertensive Retinopathy two codes are necessary. First assign code H35.033 and then code I10 to indicate the type of hypertension.
What is the ICD-10-CM code for essential HTN? A. I15.9 B. I10 C. I11.9 D. I15
B. I10 HTN is the medical abbreviation for hypertension. In the Alphabetic Index, look for Hypertension, hypertensive (accelerated) (benign) (essential) (idiopathic) (malignant) (systemic). The code next to Hypertension is I10. In the Tabular List locate code I10 and validate that it is the correct code for essential hypertension.
What are the correct codes for benign hypertensive heart disease and stage 3 chronic kidney disease? A. I10, I12.9, I11.9, N18.3 B. I13.10, N18.3 C. N18.3, I13.10 D. I12.9, N18.3
B. I13.10, N18.3 There is a combination code for hypertensive heart and chronic kidney disease, so that code is used instead of a combination of others. Code I13.10, Hypertensive heart and chronic kidney disease, without heart failure and with chronic kidney disease stage I through stage IV or unspecified, has a use additional note that states to code the stage of CKD as a secondary code. Code N18.3 is the correct code for stage 3 chronic kidney disease. The codes must be sequenced with the hypertension code first.
A patient presents with symptoms of chest pain, nausea, and pain in the neck and arm. He is diagnosed with a STEMI (or ST Elevation) myocardial infarction of the anterior wall. What ICD-10-CM codes are reported? A. I21.29 B. I21.09 C. I21.09, R07.9, R11.0, M54.2, M79.629 D. I21.29, R07.89
B. I21.09 A STEMI is an ST Elevated Myocardial Infarction. In the alphabetic Index look-up Infarct, infarction/myocardial/ST Elevation/anterior, which leads to I21.09. Chest pain, nausea, and pain in the neck and arm are symptoms of the MI and not separately reported.
The patient is being treated for acute-on-chronic pansinusitis. What ICD-10-CM code(s) is/are reported? A. J32.4, J01.40 B. J01.40, J32.4 C. J32.4 D. J01.40
B. J01.40, J32.4 According to ICD-10-CM guideline I.B.8 indicates when the same condition is described as both acute (subacute) and chronic, code both and sequence the acute (subacute) code first. From the Alphabetic Index look for Pansinusitis/acute. This refers you to J01.40. Look for Pansinusitis (chronic). This refers you to J32.4.
What is the ICD-10-CM code for back pain? A. M54.5 B. M54.9 C. M54.6 D. M54.40
B. M54.9 In the Alphabetic Index, look for Pain/back. You are referred to M54.9. In the Tabular List locate validate code M54.9 is the correct code for back pain.
Mrs. Baker was given Clonidine for her hypertension. She is only is supposed to take one tablet in the morning. She mistakenly takes two tablets and is now feeling dizzy and nauseated. She is told by her primary care physician to go to the ED and he will meet her there. What ICD-10-CM code(s) is/are reported? A. R42, R11.0, T46.5X1A B. T46.5X1A, R42, R11.0 C. T46.5X5A, R42, R11.0 D. T46.5X1A
B. T46.5X1A, R42, R11.0
Patient presents with nausea, breast tenderness, having missed her period for the second month. A pregnancy test is performed that shows a positive result. What ICD-10-CM code(s) is/are reported? A. Z34.81 B. Z32.01 C. N91.2 D. N91.2, Z32.01
B. Z32.01 In the ICD-10-CM codebook, look in the Alphabetic index for Encounter (with health service) (for)/pregnancy/test/result positive which leads to Z32.01. Z34.81, Supervision of a pregnancy is not stated. N91.2 for amenorrhea is not documented as the patient is missing her period because she is pregnant.
How many chapters does ICD-10-CM contain? A. 17 B. 19 C. 21 D. 20
C. 21 There are 21 chapters in ICD-10-CM because the eye, ear, and nervous system all have their own chapters and the External cause codes and Factors influencing health status codes have their own chapters.
In looking at the notes with this code, which statement is TRUE? K67 Disorders of the peritoneum in infectious diseases classified elsewhere Code first underlying disease, such as: congenital syphilis (A50.0) helminthiasis (B65.0-B83.9) Excludes1: peritonitis in chlamydia (A74.81) peritonitis in diphtheria (A36.89)peritonitis in gonococcal (A54.85)peritonitis in syphilis (late) (A52.74) peritonitis in tuberculosis (A18.31) A. Code K67 may be a first-listed code B. Code K67 may be coded with code A36.89 C. Code K67 may never be coded with codes listed under Excludes1 D. Code K67 is a secondary code with codes from Excludes1 being coded first
C. Code K67 may never be coded with codes listed under Excludes1 The code first note indicates that something else (the underlying disease) must be coded before code K67. The Excludes1 note indicates that none of the other conditions listed with the Excludes1 note may be coded with code K67.
A diabetic patient presents with non-pressure diabetic ulcers on the right mid-foot. The necrosis is through the soft tissue, the underlying muscle and tendon with suspected gangrene. He is scheduled for debridement. What code(s) is/are reported for this case? A. E10.621, L97.403 B. E11.621, I96, L97.403 C. E11.621, L97.403 D. E11.621
C. E11.621, L97.403 The diabetes is the underlying disease and is the first listed diagnosis. In the alphabetic index look-up Diabetes, diabetic (mellitus) (sugar)/with/foot ulcer leading to E11.621. Gangrene is suspected but not confirmed and is not reported. In the Tabular List there is an instructional note under code E11.621which states to use an additional code to identify the site of the ulcer (L97.4-, L97.5-), which are specific to depth. Report code L97.403 as the second diagnosis.
If a patient has acute diastolic heart failure, what is the main term that is used in the Alphabetic Index? A. Heart B. Acute C. Failure D. Diastolic
C. Failure The main term is the disease, illness, or condition of the patient. In this case the disease is failure of the heart. The main term is failure, with subterms heart, diastolic, and acute.
What is the ICD-10-CM code for a sore throat? A. J02.8 B. J02.0 C. J02.9 D. J31.2
C. J02.9 In the Alphabetic Index, look for sore/Throat - you are referred to see also Pharyngitis. Look for Pharyngitis and you are referred to code J02.9. In the Tabular List locate code J02.9, Acute pharyngitis, unspecified. The inclusion terms below J02.9 list sore throat (acute) NOS.
What is the ICD-10-CM code for GERD? A. P78.83 B. K21.0 C. K21.9 D. K22.8
C. K21.9 GERD is the medical abbreviation for Gastroesophageal Reflux Disease. Option 1: In the Alphabetic Index, look for GERD and you are referred to code K21.9. Option 2: In the Alphabetic Index, look for Reflux/gastroesophageal and you are referred to the same code, K21.9. In the Tabular List locate code K21.9 Gastro-esophageal reflux disease without esophagitis.
Patient is diagnosed with a pressure ulcer of the heel. What ICD-10-CM code is reported? A. L89.601 B. L89.6 C. L89.609 D. L89.600
C. L89.609 In the ICD-10-CM Alphabetic Index look for Ulcer/pressure/heel which leads to subcategory L89.6. Turn to this subcategory in the Tabular List. Information is not given as to which side or what stage the ulcer is, therefore, code L89.609 is correct.
A patient returns to her doctor three days later with nausea and rash due to taking Celebrex, a non-steroidal anti-inflammatory drug (NSAID). The physician notes that this is a drug reaction to the Celebrex and changes the medication. What ICD-10-CM code(s) is/are reported? A. T39.395A B. R11.0, L21, T39.395A C. R11.0, L27.0, T39.395A D. T39.391A, R11.0, L21, T39.395A
C. R11.0, L27.0, T39.395A ICD-10-CM Coding guidelines I.C.19.e.5) (a) indicates: When coding an adverse effect of a drug that has been correctly prescribed and properly administered, assign the appropriate code for the adverse effect of the drug (T36-T50). For the scenario the effects of the drug were nausea (R11.0) and a rash due to the drug (L27.0). Do not use the code for rash, L21, as there is a more definitive code which is rash due to the internal use of drugs. Next, report the T code. In the Table of Drugs look for Anti-inflammatory drug/nonsteroidal/Adverse effect (column). You are referred to T39.395, which needs a 7th character A to indicate this is the initial encounter.
What general guideline is addressed in I.C.1.2.c.? A. Documentation unclear as to whether sepsis or severe sepsis is present on admission B. Other codes for MRSA C. Whether the patient is newly diagnosed D. Code only confirmed cases
C. Whether the patient is newly diagnosed Section I. Conventions, general coding guidelines and chapter specific guidelines Section I.C. Chapter-Specific Coding Guidelines Section I.C.1 Chapter 1: Certain Infectious and Parasitic Diseases A00-B99 Section I.C.1.2 Selection and sequencing of HIV codes Section I.C.1.2.c Whether the patient is newly diagnosed
Two-month-old sees her pediatrician for a well-child visit and vaccinations. During the examination the patient has a diaper rash. The physician prescribes an ointment for the rash. What is/are correct ICD-10-CM code(s) to report for this encounter? A. Z00.129, L22 B. L22 C. Z00.129, Z23, L22 D. L22, Z23, Z00.129
C. Z00.129, Z23, L22 According to ICD-10-CM guidelines section I.C.21.d.13: During a routine exam, should a diagnosis or condition be discovered, it should be coded as an additional code. From the Alphabetic Index, look for Examination/child (over 28 days old). You are referred to Z00.129. Guideline I.C.21.c.2. states to use code Z23 as a secondary code if the inoculation is given as a routine part of a preventive health care. Next, look for Rash/diaper. You are referred to L22. Reference all codes in the Tabular List.
When a patient is admitted for chemotherapy for cancer what code is reported as the first listed diagnosis? A. C80.1 B. Z51.1 C. Z51.11 D. Z51.12
C. Z51.11 ICD-10-CM guideline I.C.2.e.2 states if a patient admission/encounter is solely for the administration of chemotherapy, assign code Z51.11 as the first-listed or principal diagnosis. From the Index, reference Chemotherapy (session) (for)/cancer Z51.11. Verify the code in the Tabular List.
In looking at the following listing in the Alphabetic Index, what can you tell about the codes for Alzheimer's disease with behavioral disturbance? Disease, diseased Alzheimer's G30.9 [F02.80] with behavioral disturbance G30.9 [F02.81] A. Only one code is required B. Two codes are required with code F02.81 coded first C. Two codes are required and it does not matter which one is coded first D. Two codes are required with code G30.9 coded first
D. Two codes are required with code G30.9 coded first [ ] Brackets are used to indicate multiple codes are required. The code in the brackets is always sequenced after the code that appears before the brackets.
The patient just turned 50 and is here today for a screening colonoscopy. During the procedure, two polyps are found and removed with a snare technique. What ICD-10-CM code(s) is/are reported? A. K63.5, Z12.11 B. Z12.11 C. K63.5 D. Z12.11, K63.5
D. Z12.11, K63.5 ICD-10-CM Guidelines, Section I.C.21.c.5), indicates, "A screening code may be a first listed code if the reason for the visit is specifically the screening exam...Should a condition be discovered during the screening then the code for the condition may be assigned as an additional diagnosis." For the question the screening code is reported first. From the Alphabetic Index look for Screening/colonoscopy. This refers you to Z12.11. Then look for Polyp/colon. This refers you to K63.5.
