CPC GUIDELINES| 155 QUESTIONS| WITH COMPLETE
SOLUTIONS
When is it acceptable to code signs and symptoms? Correct Answer: When a diagnosis has not
been confirmed
Should signs and symptoms that are associated routinely with a disease process be assigned as
additional codes? Correct Answer: No, unless otherwise instructed by the classification
Should signs and symptoms that are not associated routinely with a disease process be assigned
as additional codes? Correct Answer: Yes.
If the same condition is described as both acute and chronic, and separate sub-entries exist in the
Alphabetic Index at the same indentation level, how should the encounter be coded? Correct
Answer: Code both and sequence the acute code first.
A single code used to classify two diagnoses, or a diagnosis with an associated secondary
process(manifestation), or a diagnosis with an associated complication is referred to as? Correct
Answer: Combination Code
The residual effect after the acute phase of an illness or injury has terminated is referred to as?
Correct Answer: Sequela (Late Effect)
Is there a time limit on when a sequela can be used Correct Answer: No
When coding sequela how many codes are required? Correct Answer: Two
The condition of the sequela is sequenced first
The sequela code is sequenced second
The only exception to this is when manifestations exist
When coding sequela should the code for the acute phase of an illness or injury that led to the
sequela be used? Correct Answer: No
When coding conditions described as "impending" or "threatened", what should be reported if it
did occur? Correct Answer: Code as a confirmed diagnosis
How many times can each unique ICD-10-CM diagnosis code be reported per encounter?
Correct Answer: Once.
This applies to bilateral conditions when there are no distinct codes identifying laterality or two
different conditions classified to the same ICD-10-CM code
If no bilateral code is provided and the condition is bilateral, how should the encounter be
coded? Correct Answer: Assign separate codes for both the left and right side. If the side is not
identified in the MR assign the code for the unspecified side
, Which physician should be the one responsible for documenting BMI, non-pressure ulcers, and
pressure ulcer stages? Correct Answer: Patient's primary provider
When should BMI codes be reported as first listed diagnosis?? Correct Answer: Never
How should we code syndromes using ICD-10-CM guidelines Correct Answer: Follow the
alphabetic index guidance
When coding syndromes and the alphabetic index does not proving any guidance, how should
the encounter be coded? Correct Answer: Assign codes for the documented manifestations of
the syndrome
Additional codes for manifestations that are not an integral part of the disease process may also
be assigned when the condition does not have a unique code
When is it appropriate to assign codes for complications of care? Correct Answer: There must
be a cause and effect relationship between the care provided and the condition, and an indication
in the documentation that it is a complication
If the provider documents "borderline" diagnosis at the time of discharge, how is the diagnosis
coded? Correct Answer: Diagnosis is coded as confirmed unless the classification provides a
specific entry (e.g., borderline diabetes)
If a definitive diagnosis has not been established by the end of the encounter, it is appropriate to
report codes for __________________ in lieu of a definitive diagnosis. Correct Answer: Sign(s0
and/or symptom(s)
When sufficient clinical information isn't known or available about a particular health condition
to assign a more specific code, how should the encounter be coded? Correct Answer: It is
acceptable to report the appropriate unspecified code
When it is appropriate to code HIV infection/illness(es)?? Correct Answer: Code only
confirmed cases of HIV/illness
Does HIV confirmation required documentation of positive serology or culture for HIV? Correct
Answer: No. The provider's diagnostic statement that the patient is HIV positive, or has an HIV-
related illness is sufficient
If a patient is admitted for an HIV-related condition, what should the principal diagnosis be?
Correct Answer: B20; followed by additional diagnosis codes for all reported HIV-related
conditions
If a patient with HIV disease is admitted for an unrelated condition, what should be coded as the
principal diagnosis? Correct Answer: The code for the unrelated condition should be the
SOLUTIONS
When is it acceptable to code signs and symptoms? Correct Answer: When a diagnosis has not
been confirmed
Should signs and symptoms that are associated routinely with a disease process be assigned as
additional codes? Correct Answer: No, unless otherwise instructed by the classification
Should signs and symptoms that are not associated routinely with a disease process be assigned
as additional codes? Correct Answer: Yes.
If the same condition is described as both acute and chronic, and separate sub-entries exist in the
Alphabetic Index at the same indentation level, how should the encounter be coded? Correct
Answer: Code both and sequence the acute code first.
A single code used to classify two diagnoses, or a diagnosis with an associated secondary
process(manifestation), or a diagnosis with an associated complication is referred to as? Correct
Answer: Combination Code
The residual effect after the acute phase of an illness or injury has terminated is referred to as?
Correct Answer: Sequela (Late Effect)
Is there a time limit on when a sequela can be used Correct Answer: No
When coding sequela how many codes are required? Correct Answer: Two
The condition of the sequela is sequenced first
The sequela code is sequenced second
The only exception to this is when manifestations exist
When coding sequela should the code for the acute phase of an illness or injury that led to the
sequela be used? Correct Answer: No
When coding conditions described as "impending" or "threatened", what should be reported if it
did occur? Correct Answer: Code as a confirmed diagnosis
How many times can each unique ICD-10-CM diagnosis code be reported per encounter?
Correct Answer: Once.
This applies to bilateral conditions when there are no distinct codes identifying laterality or two
different conditions classified to the same ICD-10-CM code
If no bilateral code is provided and the condition is bilateral, how should the encounter be
coded? Correct Answer: Assign separate codes for both the left and right side. If the side is not
identified in the MR assign the code for the unspecified side
, Which physician should be the one responsible for documenting BMI, non-pressure ulcers, and
pressure ulcer stages? Correct Answer: Patient's primary provider
When should BMI codes be reported as first listed diagnosis?? Correct Answer: Never
How should we code syndromes using ICD-10-CM guidelines Correct Answer: Follow the
alphabetic index guidance
When coding syndromes and the alphabetic index does not proving any guidance, how should
the encounter be coded? Correct Answer: Assign codes for the documented manifestations of
the syndrome
Additional codes for manifestations that are not an integral part of the disease process may also
be assigned when the condition does not have a unique code
When is it appropriate to assign codes for complications of care? Correct Answer: There must
be a cause and effect relationship between the care provided and the condition, and an indication
in the documentation that it is a complication
If the provider documents "borderline" diagnosis at the time of discharge, how is the diagnosis
coded? Correct Answer: Diagnosis is coded as confirmed unless the classification provides a
specific entry (e.g., borderline diabetes)
If a definitive diagnosis has not been established by the end of the encounter, it is appropriate to
report codes for __________________ in lieu of a definitive diagnosis. Correct Answer: Sign(s0
and/or symptom(s)
When sufficient clinical information isn't known or available about a particular health condition
to assign a more specific code, how should the encounter be coded? Correct Answer: It is
acceptable to report the appropriate unspecified code
When it is appropriate to code HIV infection/illness(es)?? Correct Answer: Code only
confirmed cases of HIV/illness
Does HIV confirmation required documentation of positive serology or culture for HIV? Correct
Answer: No. The provider's diagnostic statement that the patient is HIV positive, or has an HIV-
related illness is sufficient
If a patient is admitted for an HIV-related condition, what should the principal diagnosis be?
Correct Answer: B20; followed by additional diagnosis codes for all reported HIV-related
conditions
If a patient with HIV disease is admitted for an unrelated condition, what should be coded as the
principal diagnosis? Correct Answer: The code for the unrelated condition should be the
