The physician visits his patient in the hospital and indicates that the patient has diabetes. Insulin is
prescribed for and administered to the patient. What is the best decision that the coding professional
can make in this situation?
A.Assign a code for type 1 diabetes mellitus because insulin was administered.
B.Assign a code for drug-induced diabetes mellitus.
C.Assign a code for type 2 diabetes mellitus with complications.
D.Assign a code for type 2 diabetes mellitus along with a code for the insulin use. - ANSWERD.
If the type of diabetes mellitus is not documented in the health record, the default is type 2 diabetes
mellitus. The coding professional would also want to code the insulin use in addition to the diabetic
code selected (CMS 2023a, I.C.4.a.2)
The patient is seen in the emergency department (ED) with acute lumbar pain. The ED physician
documents possible kidney stones and orders an x-ray. The radiologist documents bilateral
nephrolithiasis. The coding professional would assign a code for which of the following conditions?
A. Acute lumbar pain
B.Bilateral nephrolithiasis
C.Possible kidney stones
D.Abnormal x-ray findings - ANSWERB.
A radiologist's findings may be used to clarify an outpatient's diagnosis or reason for services. Based on
the fact that the radiologist is a physician, a coding professional can use a diagnosis from the x-ray (CMS
2023a, IV.K).
A female infant was born in the hospital at term and at a normal birth weight. It was a vaginal delivery
with a vertex presentation. In the hours after birth, jaundice was noted and eventually a diagnosis of
erythroblastosis fetalis due to an ABO incompatibility was made. How would this admission be coded?
Z38.00 Single liveborn infant, born in hospital, delivered vaginally
P55.0 Rh isoimmunization of newborn
, P55.1 ABO isoimmunization of newborn
P55.8 Other hemolytic diseases of newborn
P55.9 Hemolytic disease of newborn, unspecified
A.Z38.00, P55.0
B.Z38.00, P55.1
C.Z38.00, P55.8
D.Z38.00, P55.9 - ANSWERB.
Infants born to RH-negative mothers often develop hemolytic disease owing to fetal-maternal blood
group incompatibility. These conditions are classified to Category P55, Hemolytic disease of newborn
(Optum 2022, 8; ICD-10-CM Expert for Hospitals, Alphabetic Index, main term Disease, subterm
hemolytic).
The patient is seen in his ophthalmologist's office and treated for bilateral open angle glaucoma,
moderate stage. How would this encounter be coded?
H40.10X2 Unspecified open-angle glaucoma, moderate stage
H40.1111 Primary open-angle glaucoma, right eye, mild stage
H40.1112 Primary open-angle glaucoma, right eye, moderate stage
H40.9 Unspecified glaucoma
A.H40.10X2
B.H40.1111
C.H40.9
D.H40.1112 - ANSWERA.
When a patient has bilateral glaucoma and both eyes are documented as being the same type and
stage, and the classification does not provide a code for bilateral glaucoma (namely, subcategories
H40.10, and H40.20) report only one code for the type of glaucoma with the seventh character
specifying the stage (CMS 2023a, I.C.7.a.2).
Inpatient admission: The patient is a 78-year-old female with heart palpitations and abdominal pain who
was brought to the ED by her grandson. The physician ordered an EKG, a complete blood count, and
prescribed for and administered to the patient. What is the best decision that the coding professional
can make in this situation?
A.Assign a code for type 1 diabetes mellitus because insulin was administered.
B.Assign a code for drug-induced diabetes mellitus.
C.Assign a code for type 2 diabetes mellitus with complications.
D.Assign a code for type 2 diabetes mellitus along with a code for the insulin use. - ANSWERD.
If the type of diabetes mellitus is not documented in the health record, the default is type 2 diabetes
mellitus. The coding professional would also want to code the insulin use in addition to the diabetic
code selected (CMS 2023a, I.C.4.a.2)
The patient is seen in the emergency department (ED) with acute lumbar pain. The ED physician
documents possible kidney stones and orders an x-ray. The radiologist documents bilateral
nephrolithiasis. The coding professional would assign a code for which of the following conditions?
A. Acute lumbar pain
B.Bilateral nephrolithiasis
C.Possible kidney stones
D.Abnormal x-ray findings - ANSWERB.
A radiologist's findings may be used to clarify an outpatient's diagnosis or reason for services. Based on
the fact that the radiologist is a physician, a coding professional can use a diagnosis from the x-ray (CMS
2023a, IV.K).
A female infant was born in the hospital at term and at a normal birth weight. It was a vaginal delivery
with a vertex presentation. In the hours after birth, jaundice was noted and eventually a diagnosis of
erythroblastosis fetalis due to an ABO incompatibility was made. How would this admission be coded?
Z38.00 Single liveborn infant, born in hospital, delivered vaginally
P55.0 Rh isoimmunization of newborn
, P55.1 ABO isoimmunization of newborn
P55.8 Other hemolytic diseases of newborn
P55.9 Hemolytic disease of newborn, unspecified
A.Z38.00, P55.0
B.Z38.00, P55.1
C.Z38.00, P55.8
D.Z38.00, P55.9 - ANSWERB.
Infants born to RH-negative mothers often develop hemolytic disease owing to fetal-maternal blood
group incompatibility. These conditions are classified to Category P55, Hemolytic disease of newborn
(Optum 2022, 8; ICD-10-CM Expert for Hospitals, Alphabetic Index, main term Disease, subterm
hemolytic).
The patient is seen in his ophthalmologist's office and treated for bilateral open angle glaucoma,
moderate stage. How would this encounter be coded?
H40.10X2 Unspecified open-angle glaucoma, moderate stage
H40.1111 Primary open-angle glaucoma, right eye, mild stage
H40.1112 Primary open-angle glaucoma, right eye, moderate stage
H40.9 Unspecified glaucoma
A.H40.10X2
B.H40.1111
C.H40.9
D.H40.1112 - ANSWERA.
When a patient has bilateral glaucoma and both eyes are documented as being the same type and
stage, and the classification does not provide a code for bilateral glaucoma (namely, subcategories
H40.10, and H40.20) report only one code for the type of glaucoma with the seventh character
specifying the stage (CMS 2023a, I.C.7.a.2).
Inpatient admission: The patient is a 78-year-old female with heart palpitations and abdominal pain who
was brought to the ED by her grandson. The physician ordered an EKG, a complete blood count, and
