ICD-10-CM quiz bank

Correct answer: B. Invalid

Rationale. Convention I.A.2 states that a code with an applicable 7th character is considered invalid without the 7th character. Convention I.A.3 adds that any applicable 7th character is required for reporting. Whether the record documents the information needed is a documentation problem to be resolved, not a reason to report an invalid code.

Correct answer: C. Both code A and code B

Rationale. Convention I.A.12.a provides an exception to the Excludes1 definition for the circumstance in which the two conditions are unrelated to each other — both codes may then be reported. The guideline's own example is F45.8 with G47.63. A query is required only when it is not clear whether the two conditions are related.

Correct answer: B. The subentry for chronic

Rationale. Convention I.A.7 states that nonessential modifiers apply to subterms following a main term except where a nonessential modifier and a subentry are mutually exclusive — in which case the subentry takes precedence. Acute and chronic are mutually exclusive here, so the chronic subentry governs.

Correct answer: C. The provider's statement that the condition exists is sufficient; if the record contains conflicting documentation, query the provider

Rationale. Convention I.A.19 states that code assignment is based on the provider's diagnostic statement that the condition exists, that the statement is sufficient, and that code assignment is not based on the clinical criteria the provider used. The guideline's own remedy for a problem in the record is a query where there is conflicting documentation — not unilateral refusal or downgrading of the code.

Correct answer: B. The bracketed code is always sequenced second

Rationale. Convention I.A.13 states that in the Alphabetic Index both conditions are listed together with the etiology code first, followed by the manifestation code in brackets, and that the code in brackets is always to be sequenced second. In the Tabular List, brackets have a different job — they enclose synonyms, alternative wording or explanatory phrases.

Correct answer: B. The bilateral code

Rationale. Guideline I.B.13 is explicit: when a patient has a bilateral condition and each side is treated during separate encounters, assign the bilateral code, including for the encounter to treat the first side, because the condition still exists on both sides. The unilateral code becomes appropriate only at the second encounter, once the condition no longer exists on the treated side.

Correct answer: C. Neither code

Rationale. Two guidelines combine here. I.B.14 permits BMI to be coded from a clinician other than the provider, but requires the associated diagnosis to be documented by the patient's provider. Section I.C.21.c.3 adds that BMI codes should only be assigned when there is an associated, reportable diagnosis documented by the provider. With no such diagnosis there is nothing to attach the BMI code to, so neither code is reported. Querying the provider is the appropriate next step.

Correct answer: B. The scar, then the burn code with 7th character S

Rationale. Guideline I.B.10 requires two codes with the nature of the sequela sequenced first and the sequela code second. Section I.C.19.a adds that the 7th character S is added only to the injury code, not to the sequela code, and that the specific type of sequela such as a scar is sequenced first. There is no time limit on when a sequela code may be used, and the code for the acute phase is never reported with the late effect.

Correct answer: B. Code it as confirmed hypertension unless the classification provides a specific borderline entry

Rationale. Guideline I.B.17 states that a borderline diagnosis documented at the time of discharge is coded as confirmed, unless the classification provides a specific entry such as borderline diabetes, and that because borderline conditions are not uncertain diagnoses no distinction is made between inpatient and outpatient. The guideline also encourages a query where documentation about a borderline condition is unclear.

Correct answer: B. Once

Rationale. Guideline I.B.12 states that each unique ICD-10-CM diagnosis code may be reported only once for an encounter, and applies that rule both to bilateral conditions where no distinct laterality codes exist and to two different conditions classified to the same ICD-10-CM diagnosis code.

Correct answer: B. B20 as a secondary diagnosis, with the fracture as principal diagnosis

Rationale. Two rules combine. Guideline I.C.1.a.2.g states that once an HIV-related illness has developed, B20 should always be assigned on every subsequent admission or encounter, and such a patient may never be assigned Z21 or R75. Guideline I.C.1.a.2.c states that where an HIV disease patient is admitted for an unrelated condition such as a traumatic injury, the unrelated condition is the principal diagnosis and B20 is reported as a secondary diagnosis.

Correct answer: B. The sepsis code and the acute kidney injury code, with no code from R65.2

Rationale. Guideline I.C.1.d.1.a.iv states that if a patient has sepsis and an acute organ dysfunction but the documentation indicates the acute organ dysfunction is related to a medical condition other than the sepsis, a code from R65.2 is not assigned. The acute organ dysfunction must be associated with the sepsis to justify the severe sepsis code. Where the documentation is unclear on that link, the provider is queried — here it is not unclear, it is documented as unrelated.

Correct answer: B. T81.41- or the applicable site code, T81.44, the infectious agent, R65.2-, J96.0-

Rationale. Guideline I.C.1.d.5.b directs that for sepsis following a postprocedural wound infection, a code from T81.41 to T81.43, or T81.49, identifying the site of the infection is sequenced first if known, followed by T81.44 sepsis following a procedure, with an additional code to identify the infectious agent. If the patient has severe sepsis, R65.2- is also assigned with codes for any acute organ dysfunction.

Correct answer: B. Z22.322

Rationale. Guideline I.C.1.e.1.c states that Z22.322, carrier or suspected carrier of MRSA, is assigned for patients documented as having MRSA colonisation, and names “MRSA screen positive” and “MRSA nasal swab positive” as the typical documentation. Colonisation is not necessarily indicative of a disease process unless the provider documents it as such, so no infection or resistance code is assigned.

Correct answer: C. O98.5-

Rationale. Guideline I.C.1.g.1.b states that U07.1 is sequenced first when COVID-19 meets the definition of principal diagnosis except where another guideline requires certain codes to be sequenced first, naming obstetrics among them. Guideline I.C.15.s is that guideline: O98.5- is sequenced as the principal diagnosis, followed by U07.1 and the codes for associated manifestations. Chapter 15 codes always take sequencing priority.

Correct answer: B. The secondary malignant neoplasm of the liver

Rationale. Guideline I.C.2.b states that when a patient is admitted because of a primary neoplasm with metastasis and treatment is directed toward the secondary site only, the secondary neoplasm is designated as the principal diagnosis even though the primary malignancy is still present. Guideline I.C.2.l.2 repeats the rule and adds that the primary malignancy is coded as an additional code.

Correct answer: B. The malignant neoplasm of the prostate

Rationale. Guideline I.C.2.e.2 is explicit: if the admission or encounter is for the insertion or implantation of radioactive elements, for example brachytherapy, the appropriate code for the malignancy is sequenced as the principal or first-listed diagnosis and Z51.0 should not be assigned. Z51.0 is reserved for external beam radiation therapy.

Correct answer: B. The anemia, then the lymphoma, then T45.1X5-

Rationale. Guideline I.C.2.c.2 states that when the encounter is for management of an anemia associated with an adverse effect of the administration of chemotherapy or immunotherapy and the only treatment is for the anemia, the anemia code is sequenced first, followed by the appropriate codes for the neoplasm and the adverse effect, T45.1X5-. This is the mirror image of guideline I.C.2.c.1, where the anemia is associated with the malignancy itself and the malignancy is sequenced first with D63.0.

Correct answer: B. A code from C81-C85 with a final character identifying extranodal and solid organ sites

Rationale. Guideline I.C.2.t states that when a malignant neoplasm of lymphoid tissue metastasises beyond the lymph nodes, a code from categories C81-C85 with a final character identifying extranodal and solid organ sites is assigned rather than a code for the secondary neoplasm of the affected solid organ. The guideline's own worked example is this exact clinical picture, assigned to C83.398.

Correct answer: B. A code from Z85

Rationale. Guideline I.C.2.d and I.C.2.m both provide that when a primary malignancy has been previously excised or eradicated from its site, there is no further treatment directed to that site, and there is no evidence of any existing primary malignancy at that site, a code from category Z85 personal history of malignant neoplasm is used. Z85.3 is the breast subcategory; Z85.89 is reserved for the former site of either a primary or a secondary malignancy where the specific subcategories do not apply.

Correct answer: B. The entry reads “reserved for future guideline expansion”

Rationale. The FY 2027 guidelines list Chapter 3 (D50-D89) with the single line “Reserved for future guideline expansion”. Chapters 8 and 11 carry the same entry. This is not the same as a deleted guideline: Section II.E and Section I.C.18.f are marked as deleted, with the effective date of deletion.

Correct answer: B. The multiple myeloma code

Rationale. Guideline I.C.2.c.1 provides that when the admission or encounter is for management of an anemia associated with the malignancy, and the treatment is only for the anemia, the appropriate code for the malignancy is sequenced as the principal or first-listed diagnosis followed by the appropriate code for the anemia, such as D63.0. Chapter 3 has no guideline of its own that would change this.

Correct answer: B. D59.31

Rationale. Guideline I.C.1.d.9 states that if the reason for admission is hemolytic-uremic syndrome that is associated with sepsis, D59.31 infection-associated hemolytic-uremic syndrome is assigned as the principal diagnosis, with codes for the underlying systemic infection and any other conditions such as severe sepsis assigned as secondary diagnoses. This is one of the few situations in which a code outranks the systemic infection in a sepsis case.

Correct answer: C. The Section I.A conventions, the Section I.B general guidelines, the Tabular List instructional notes, and Sections II, III and IV

Rationale. A reserved chapter is not an unregulated chapter. Section I states that the conventions and instructions of the classification take precedence over the guidelines, and the general guidelines in Section I.B apply to the whole classification. Where Section I.C is silent, those sources plus the reporting rules in Sections II, III and IV carry the full weight.

Correct answer: B. Z79

Rationale. Category Z79, long-term (current) drug therapy, indicates a patient's continuous use of a prescribed drug for the long-term treatment of a condition or for prophylactic use. Section I.C.21.c.3 directs that a code from Z79 be assigned where a medication is given for an extended period as a prophylactic measure or as treatment of a chronic condition, and that it not be assigned for medication given briefly to treat an acute illness. Z79 is not for patients with drug addictions and not for detoxification or maintenance programmes.

Correct answer: B. E11.9 and Z79.4

Rationale. Guideline I.C.4.a.3 provides that if the documentation does not indicate the type of diabetes but does indicate that the patient uses insulin, E11.- type 2 diabetes mellitus should be assigned, with an additional code from category Z79 to identify the long-term use of insulin. Guideline I.C.4.a.2 sets E11.- as the default where the type is not documented at all.

Correct answer: C. Z79.84 only

Rationale. Guideline I.C.4.a.3 states that Z79.4 should not be assigned if insulin is given temporarily to bring a type 2 patient's blood sugar under control during an encounter. The home metformin is long-term oral hypoglycemic therapy, so Z79.84 is assigned. The same restriction on Z79.4 is repeated at I.C.4.a.6.a for secondary diabetes.

Correct answer: C. T85.6-

Rationale. Guideline I.C.4.a.5.a directs that an underdose of insulin due to an insulin pump failure is assigned to a code from subcategory T85.6 that specifies the type of pump malfunction, as the principal or first-listed code, followed by T38.3X6- underdosing of insulin and oral hypoglycemic drugs, then codes for the type of diabetes and any associated complications due to the underdosing. The same principal code applies to a pump malfunction causing an overdose, with T38.3X1- second.

Correct answer: B. Only the code for class 3 obesity

Rationale. Guideline I.C.4.b.1 states that if both class 3 obesity and morbid obesity are documented, only a code for class 3 obesity should be assigned as it is more specific. The obesity class codes in subcategory E66.81 otherwise may be reported with other obesity codes in Chapters 4 and 15 to fully describe the condition, and require the class to be documented by the provider.

Correct answer: B. A code from category E13 as the principal or first-listed diagnosis, with Z90.41- as an additional code

Rationale. Guideline I.C.4.a.6.b.i covers secondary diabetes mellitus due to pancreatectomy: for postpancreatectomy diabetes mellitus, meaning lack of insulin due to the surgical removal of all or part of the pancreas, assign E89.1 postprocedural hypoinsulinemia, and assign a code from category E13 as the principal or first-listed diagnosis with a code from subcategory Z90.41 acquired absence of pancreas as an additional code.

Correct answer: C. One — the code for dependence

Rationale. Guideline I.C.5.b.2 states that when provider documentation refers to use, abuse and dependence of the same substance, only one code should be assigned to identify the pattern of use, following a hierarchy in which dependence outranks abuse and abuse outranks use. With all three documented for the same substance, only the code for dependence is assigned.

Correct answer: B. K85.2- and F10.20

Rationale. Guideline I.C.5.b.4 states that medical conditions due to substance use, abuse and dependence are not classified as substance-induced disorders, and that the diagnosis code for the medical condition should be assigned as directed by the Alphabetic Index along with the appropriate psychoactive substance use, abuse or dependence code. The guideline uses this exact example and states that it would not be appropriate to assign F10.288.

Correct answer: B. The caregiver

Rationale. Guideline I.C.5.c states that in Munchausen's syndrome by proxy the perpetrator, not the victim, receives the diagnosis, and that F68.A factitious disorder imposed on another is assigned to the perpetrator's record. For the victim, the appropriate code from category T74 confirmed or T76 suspected abuse, neglect and other maltreatment is assigned.

Correct answer: B. One code for moderate severity

Rationale. Guideline I.C.5.d states that if a patient is admitted to an inpatient acute care hospital or other inpatient facility setting with dementia at one severity level and it progresses to a higher severity level, assign one code for the highest severity level reported during the stay. This differs from the pressure ulcer rule at I.C.12.a.6, which requires two codes in the analogous situation.

Correct answer: B. F45.42

Rationale. Guideline I.C.5.a directs that F45.41 is assigned for pain exclusively related to psychological disorders and that, as indicated by the Excludes1 note under category G89, a code from category G89 should not be assigned with F45.41. Code F45.42, pain disorders with related psychological factors, should be used with a code from category G89 where there is documentation of a psychological component for a patient with acute or chronic pain.

Correct answer: B. The lumbar spinal stenosis

Rationale. Guideline I.C.6.b.1 states that when an admission or encounter is for a procedure aimed at treating the underlying condition, such as a spinal fusion or kyphoplasty, a code for the underlying condition should be assigned as the principal diagnosis and no code from category G89 should be assigned. The presence of pain does not change the intent of the procedure.

Correct answer: B. The G89 code first, then the disc displacement as an additional diagnosis

Rationale. Guideline I.C.6.b.1.a states that category G89 codes are acceptable as the principal or first-listed code when pain control or pain management is the reason for the admission or encounter, and uses this exact example. The underlying cause of the pain should be reported as an additional diagnosis, if known.

Correct answer: B. The appropriate Chapter 19 code for pain due to the prosthesis, with G89.28 as an additional code

Rationale. Guideline I.C.6.b.2 refers to Section I.C.19, and I.C.19.g.2 states that pain associated with devices, implants or grafts left in a surgical site, for example a painful hip prosthesis, is assigned to the appropriate code found in Chapter 19, with additional codes from category G89 to identify acute or chronic pain due to the presence of the device, implant or graft — G89.18 or G89.28.

Correct answer: B. G89.3, with the neoplasm reported additionally

Rationale. Guideline I.C.6.b.5 states that G89.3 is assigned for pain documented as related, associated or due to cancer, a primary or secondary malignancy, or a tumour, regardless of whether the pain is acute or chronic, and that it may be assigned as the principal or first-listed code when the stated reason for the admission or encounter is documented as pain control or pain management, with the underlying neoplasm reported as an additional diagnosis. It is not necessary to assign an additional code for the site of the pain.

Correct answer: B. Dominant

Rationale. Guideline I.C.6.a sets the defaults where the affected side is documented but not specified as dominant or nondominant and the classification does not indicate a default: for ambidextrous patients the default is dominant, if the left side is affected the default is non-dominant, and if the right side is affected the default is dominant. Guideline I.C.9.d.1 applies the identical defaults to the I69 sequelae codes.

Correct answer: B. One code for the type of glaucoma for each eye, each with the 7th character for that eye's stage

Rationale. Guideline I.C.7.a.3 states that when a patient has bilateral glaucoma and each eye is documented as having the same type but a different stage, and the classification does not distinguish laterality, assign a code for the type of glaucoma for each eye with the seventh character for the specific glaucoma stage documented for each eye.

Correct answer: B. 4

Rationale. Guideline I.C.7.a.5 states that assignment of the seventh character 4 for indeterminate stage should be based on the clinical documentation, and is used for glaucomas whose stage cannot be clinically determined. It should not be confused with the seventh character 0, unspecified, which is assigned when there is no documentation regarding the stage of the glaucoma.

Correct answer: B. The code with the 7th character for the highest stage documented

Rationale. Guideline I.C.7.a.4 states that if a patient is admitted with glaucoma and the stage progresses during the admission, assign the code for the highest stage documented. This mirrors the dementia rule at I.C.5.d and contrasts with the pressure ulcer rule at I.C.12.a.6, which requires two codes.

Correct answer: B. H54.3

Rationale. Guideline I.C.7.b states that if blindness or low vision of both eyes is documented but the visual impairment category is not documented, assign H54.3, unqualified visual loss, both eyes. H54.6- is for one eye without a category, and H54.7 is for visual loss documented with no information about whether one or both eyes are affected.

Correct answer: B. Only the bilateral code, with the 7th character for the stage

Rationale. Guideline I.C.7.a.2 states that when a patient has bilateral glaucoma and both eyes are documented as being the same type and stage, and there is a code for bilateral glaucoma, report only the code for the type of glaucoma, bilateral, with the seventh character for the stage. Where no bilateral code exists for that type, the same guideline directs that only one code for the type is reported.

Correct answer: B. “Reserved for future guideline expansion”

Rationale. The FY 2027 guidelines list Chapter 8, diseases of the ear and mastoid process (H60-H95), as reserved for future guideline expansion. Chapters 3 and 11 carry the same entry. Coding in this chapter is driven entirely by the conventions, the general guidelines and the Tabular List instructional notes.

Correct answer: B. Separate codes for the right side and the left side

Rationale. Section I.B.13 states that if no bilateral code is provided and the condition is bilateral, separate codes for both the left and right side are assigned. Section I.B.12 forecloses the alternative: each unique ICD-10-CM diagnosis code may be reported only once for an encounter, which the guideline applies specifically to bilateral conditions where there are no distinct codes identifying laterality.

Correct answer: B. The combination code alone

Rationale. Section I.B.9 states that only the combination code is assigned when that code fully identifies the diagnostic conditions involved or when the Alphabetic Index so directs, and that multiple coding should not be used where the classification provides a combination code that clearly identifies all of the elements documented. Section I.B.8, which would direct two codes with the acute sequenced first, applies only where separate subentries exist at the same indentation level and no combination code covers the picture.

Correct answer: B. Chapter 1, categories B95, B96 or B97

Rationale. Section I.C.1.b states that certain infections are classified in chapters other than Chapter 1 with no organism identified as part of the infection code, and that in those instances it is necessary to use an additional code from Chapter 1 — B95 for streptococcus, staphylococcus and enterococcus, B96 for other bacterial agents, or B97 for viral agents. Section I.B.7 describes the same mechanism as multiple coding for a single condition.

Correct answer: B. Within Chapter 8, sequenced first, followed by a code for the specific complication

Rationale. Section I.C.19.g.5 states that intraoperative and postprocedural complication codes are found within the body system chapters with codes specific to the organs and structures of that body system, that these codes should be sequenced first followed by a code for the specific complication if applicable, and that body-system complication codes should be assigned unless the complication is specifically indexed to a T code in Chapter 19.

Correct answer: C. A code from I13, plus a code from I50 for the type of heart failure, plus N18.4

Rationale. Guideline I.C.9.a.3 states that the codes in category I13 are combination codes that include hypertension, heart disease and chronic kidney disease, that an additional code from I50 is assigned if heart failure is present, and that a code from N18 is used as a secondary code to identify the stage. The Includes note at I13 means that where a patient has all three, I13 is used rather than I11 or I12. No linking statement is required, because the classification presumes the causal relationship.

Correct answer: B. I21.A1 only, with the underlying cause coded first

Rationale. Guideline I.C.9.e.5 states that type 2 myocardial infarction is assigned to I21.A1 with the underlying cause coded first if applicable, that I24.89 should not be assigned for the demand ischemia, that if a type 2 AMI is described as NSTEMI or STEMI only I21.A1 is assigned, and that codes I21.01-I21.4 should only be assigned for type 1 AMIs.

Correct answer: B. A code from I22 used together with a code from I21

Rationale. Guideline I.C.9.e.4 states that a code from category I22 is used when a patient who has suffered a type 1 or unspecified AMI has a new AMI within the four-week time frame of the initial AMI, that a code from I22 must be used in conjunction with a code from I21, and that the sequencing depends on the circumstances of the encounter. Because both infarctions are type 1, I22 applies.

Correct answer: B. Non-dominant

Rationale. Guideline I.C.9.d.1 sets the defaults for I69 codes specifying hemiplegia, hemiparesis and monoplegia where the affected side is documented but not specified as dominant or nondominant: for ambidextrous patients the default is dominant, if the left side is affected the default is non-dominant, and if the right side is affected the default is dominant. The identical defaults appear at I.C.6.a for category G81.

Correct answer: B. A combination code from I25.11-

Rationale. Guideline I.C.9.b states that ICD-10-CM has combination codes for atherosclerotic heart disease with angina pectoris in subcategories I25.11 and I25.7, that when using one of these combination codes it is not necessary to use an additional code for angina pectoris, and that a causal relationship can be assumed in a patient with both atherosclerosis and angina pectoris unless the documentation indicates the angina is due to something other than the atherosclerosis.

Correct answer: B. The appropriate pneumonia code from J12-J18; query the provider about the relationship to the ventilator

Rationale. Guideline I.C.10.d.1 states that J95.851 should not be assigned for cases where the patient has pneumonia and is on a mechanical ventilator but the provider has not specifically stated that the pneumonia is ventilator-associated, and that if the documentation is unclear as to whether the pneumonia is a complication attributable to the mechanical ventilator, the provider should be queried. Code assignment for any postprocedural complication rests on the provider's documentation of the relationship.

Correct answer: C. A code from J11

Rationale. Guideline I.C.10.c states that only confirmed cases of influenza due to certain identified influenza viruses (J09) and due to other identified influenza virus (J10) are coded, that this is an exception to the inpatient uncertain-diagnosis guideline, and that if the provider records suspected, possible or probable avian, novel or other identified influenza, the appropriate code from category J11, influenza due to unidentified influenza virus, should be assigned instead.

Correct answer: B. U07.0 alone

Rationale. Guideline I.C.10.e states that for patients presenting with conditions related to vaping, U07.0 is assigned as the principal diagnosis, and that for lung injury due to vaping, only code U07.0 is assigned. Additional codes are assigned for other manifestations such as acute respiratory failure or pneumonitis — but lung injury itself is covered by U07.0.

Correct answer: C. Query the provider for clarification

Rationale. Guideline I.C.10.b.3 states that when a patient is admitted with respiratory failure and another acute condition the principal diagnosis will not be the same in every situation, that selection depends on the circumstances of admission, that where both are equally responsible and there are no chapter-specific sequencing rules Section II.C may be applied, and that if the documentation is not clear as to whether they are equally responsible, the provider should be queried.

Correct answer: B. An acute exacerbation is a worsening or decompensation of a chronic condition, and is not equivalent to a superimposed infection

Rationale. Guideline I.C.10.a.1 states that the codes in categories J44 and J45 distinguish between uncomplicated cases and those in acute exacerbation, that an acute exacerbation is a worsening or a decompensation of a chronic condition, and that an acute exacerbation is not equivalent to an infection superimposed on a chronic condition — though an exacerbation may be triggered by an infection.

Correct answer: B. “Reserved for future guideline expansion”

Rationale. The FY 2027 guidelines list Chapter 11, diseases of the digestive system (K00-K95), as reserved for future guideline expansion. Chapters 3 and 8 carry the same entry. The conventions, general guidelines and Tabular List instructional notes govern instead.

Correct answer: B. K85.2- and a code from F10.2-

Rationale. Guideline I.C.5.b.4 states that medical conditions due to substance use, abuse and dependence are not classified as substance-induced disorders, and that the code for the medical condition is assigned as directed by the Alphabetic Index along with the appropriate substance use, abuse or dependence code. The guideline uses this exact example and states it would not be appropriate to assign F10.288.

Correct answer: B. N

Rationale. Appendix I, codes that contain multiple clinical concepts, directs assignment of N if at least one of the clinical concepts included in the code was not present on admission, and uses a gastric ulcer that does not start bleeding until after admission as one of its three worked examples. Y is assigned only if all of the clinical concepts were present on admission, such as a duodenal ulcer that perforates prior to admission.

Correct answer: B. The combination code alone

Rationale. Section I.B.9 states that only the combination code is assigned when that code fully identifies the diagnostic conditions involved or when the Alphabetic Index so directs, and that multiple coding should not be used when the classification provides a combination code that clearly identifies all of the elements documented. An additional code is used only where the combination code lacks necessary specificity in describing the manifestation or complication.

Correct answer: B. Z43.3 for the encounter; Z93.3 is not added because the aftercare code already indicates the status

Rationale. Section I.C.21.c.7 states that status Z codes may be used with aftercare Z codes to indicate the nature of the aftercare, but that a status code should not be used when the aftercare code indicates the type of status — and gives the parallel example of Z43.0 attention to tracheostomy with Z93.0 tracheostomy status. Verify the exact codes in the Tabular List.

Correct answer: C. Two codes: the sacral ulcer at stage 2 and the sacral ulcer at stage 4

Rationale. Guideline I.C.12.a.6 states that if a patient is admitted to an inpatient hospital with a pressure ulcer at one stage and it progresses to a higher stage, two separate codes should be assigned: one code for the site and stage of the ulcer on admission and a second code for the same ulcer site and the highest stage reported during the stay. Contrast this with dementia and glaucoma, where only the highest level is coded.

Correct answer: B. L89.--0 unstageable

Rationale. Guideline I.C.12.a.2 states that assignment of the code for unstageable pressure ulcer, L89.--0, is based on the clinical documentation, and that these codes are used for pressure ulcers whose stage cannot be clinically determined, giving eschar and treatment with a skin or muscle graft as the examples. It is not to be confused with the codes for unspecified stage, L89.--9, which are used when there is no documentation regarding the stage.

Correct answer: B. Only the code for the stage revealed following debridement

Rationale. Guideline I.C.12.a.2 states that if, during an encounter, the stage of an unstageable pressure ulcer is revealed after debridement, assign only the code for the stage revealed following debridement. Only one code is assigned, and it is the revealed stage.

Correct answer: C. No code

Rationale. Guideline I.C.12.a.4 states plainly that no code is assigned if the documentation states that the pressure ulcer is completely healed at the time of admission. Guideline I.C.12.b.1 applies the identical rule to non-pressure chronic ulcers. Ulcers documented as healing, by contrast, are coded at the documented stage or severity, or unspecified if none is given.

Correct answer: B. The code for the site and stage of the ulcer at the time of admission

Rationale. Guideline I.C.12.a.5 states that for ulcers that were present on admission but healed at the time of discharge, assign the code for the site and stage of the pressure ulcer at the time of admission. The mirror rule for non-pressure chronic ulcers appears at I.C.12.b.2. Note the contrast with an ulcer already healed at the time of admission, which gets no code at all.

Correct answer: B. A code from category M80

Rationale. Guideline I.C.13.d.2 states that a code from category M80, not a traumatic fracture code, should be used for any patient with known osteoporosis who suffers a fracture, even if the patient had a minor fall or trauma, if that fall or trauma would not usually break a normal, healthy bone. Guideline I.C.19.c.1 repeats the same rule from the injury chapter's side.

Correct answer: A. A, initial encounter

Rationale. Guideline I.C.13.c states that 7th character A is for use as long as the patient is receiving active treatment for the fracture, and that while the patient may be seen by a new or different provider over the course of treatment for a pathological fracture, assignment of the 7th character is based on whether the patient is undergoing active treatment and not whether the provider is seeing the patient for the first time. Section I.C.19.a states the identical principle for Chapter 19.

Correct answer: B. The femur (the bone)

Rationale. Guideline I.C.13.a.1 states that for certain conditions the bone may be affected at the upper or lower end, giving avascular necrosis of bone M87 and osteoporosis M80, M81 as the examples, and that though the portion of the bone affected may be at the joint, the site designation will be the bone, not the joint.

Correct answer: B. A code from M81, followed by Z87.310

Rationale. Guideline I.C.13.d.1 states that category M81 is for use for patients with osteoporosis who do not currently have a pathologic fracture due to the osteoporosis, even if they have had a fracture in the past, and that for patients with a history of osteoporosis fractures, status code Z87.310, personal history of (healed) osteoporosis fracture, should follow the code from M81.

Correct answer: C. Query the provider

Rationale. Guideline I.C.13.b states that any current, acute injury should be coded to the appropriate injury code from Chapter 19, that chronic or recurrent conditions should generally be coded with a code from Chapter 13, and that if it is difficult to determine from the documentation in the record which code is best to describe a condition, the provider should be queried.

Correct answer: B. N18.6 only

Rationale. Guideline I.C.14.a.1 states that if both a stage of CKD and ESRD are documented, assign code N18.6 only. Code N18.6 is assigned when the provider has documented end-stage renal disease.

Correct answer: B. N18.31 and Z94.0

Rationale. Guideline I.C.14.a.2 states that patients who have undergone kidney transplant may still have some form of CKD because the transplant may not fully restore kidney function, that the presence of CKD alone does not constitute a transplant complication, and that the appropriate N18 code for the patient's stage of CKD and code Z94.0 kidney transplant status should be assigned. Guideline I.C.19.g.3.b repeats that T86.1- should not be assigned for post kidney transplant patients who have CKD unless a transplant complication is documented.

Correct answer: B. N18.30-N18.32

Rationale. Guideline I.C.14.a.1 maps severity to stage: stage 2, code N18.2, equates to mild CKD; stage 3, codes N18.30-N18.32, equate to moderate CKD; and stage 4, code N18.4, equates to severe CKD.

Correct answer: B. A code from I12 and a code from N18 for the stage

Rationale. Guideline I.C.9.a.2 directs assignment of codes from category I12 when both hypertension and a condition classifiable to category N18 are present, with the appropriate N18 code as a secondary code to identify the stage. No linking statement is needed, because the classification presumes a causal relationship between hypertension and kidney involvement under Section I.A.15. CKD is not coded as hypertensive only where the provider indicates it is not related.

Correct answer: B. T86.1- with a secondary code identifying the complication

Rationale. Guideline I.C.19.g.3.b states that code T86.1- should be assigned for documented complications of a kidney transplant, such as transplant failure or rejection or other transplant complication, and that conditions that affect the function of the transplanted kidney other than CKD should be assigned a code from subcategory T86.1 and a secondary code that identifies the complication. Guideline I.C.14.a.2 directs a query if the documentation is unclear as to whether the patient has a complication of the transplant.

Correct answer: B. A code from Chapter 15 for the condition complicating pregnancy, followed by the appendicitis code

Rationale. Guideline I.C.15.a.1 states that obstetric cases require codes from chapter 15, that chapter 15 codes have sequencing priority over codes from other chapters, and that additional codes from other chapters may be used in conjunction with chapter 15 codes to further specify conditions. Z33.1 is used in place of chapter 15 codes only where the provider documents that the pregnancy is incidental to the encounter — and the guideline places that responsibility on the provider.

Correct answer: B. Only the O24.4 insulin-controlled code

Rationale. Guideline I.C.15.i states that if a patient with gestational diabetes is treated with both diet and insulin, only the code for insulin-controlled is required, and that codes Z79.4, Z79.84 and Z79.85 should not be assigned with codes from subcategory O24.4. It also states that no other code from category O24 should be used with a code from O24.4.

Correct answer: B. O80 and Z37.0, with the gestation coded as 39 weeks

Rationale. Guideline I.C.15.n.1 makes O80 always the principal diagnosis for a full-term normal delivery of a single healthy infant with no complications, and I.C.15.n.3 states that Z37.0 is the only outcome of delivery code appropriate for use with O80. Guideline I.C.15.a.7 defines completed weeks of gestation as full weeks and uses this precise example: 39 weeks and 6 days is coded as 39 weeks, because 40 completed weeks has not been reached.

Correct answer: C. No code from O35 or O36

Rationale. Guideline I.C.15.e.1 states that codes from categories O35 and O36 are assigned only when the fetal condition is actually responsible for modifying the management of the mother — by requiring diagnostic studies, additional observation, special care or termination of pregnancy — and that the fact that the fetal condition exists does not justify assigning a code from this series to the mother's record.

Correct answer: B. Z39.0

Rationale. Guideline I.C.15.o.4 states that when the mother delivers outside the hospital prior to admission and is admitted for routine postpartum care with no complications noted, code Z39.0, encounter for care and examination of mother immediately after delivery, should be assigned as the principal diagnosis. Z37 outcome codes are for the delivery record and are always secondary.

Correct answer: B. The perinatal condition that occasioned the transfer

Rationale. Guideline I.C.16.a.2 states that a code from category Z38 is assigned only once, to a newborn at the time of birth, and that if a newborn is transferred to another institution a code from category Z38 should not be used at the receiving hospital. Guideline I.C.16.a.3 then directs that where the reason for the encounter is a perinatal condition, the code from chapter 16 should be sequenced first.

Correct answer: B. A code from category P36

Rationale. Guideline I.C.16.f states that category P36 bacterial sepsis of newborn includes congenital sepsis, and that if a perinate is documented as having sepsis without documentation of congenital or community acquired, the default is congenital and a code from category P36 should be assigned. If the P36 code includes the causal organism, no additional B95 or B96 code is assigned; if it does not, an additional code from B96 is added.

Correct answer: C. Two codes from P07, birth weight sequenced before gestational age

Rationale. Guideline I.C.16.d states that when both birth weight and gestational age are available, two codes from category P07 should be assigned, with the code for birth weight sequenced before the code for gestational age. The same guideline notes that a code for prematurity should not be assigned unless it is documented, because providers use different criteria in determining prematurity.

Correct answer: B. A code from Z38 as principal, with Z05.1- as a secondary code

Rationale. Guideline I.C.16.b.3 states that a code from category Z05 is to be used as a secondary code after the code from category Z38 on a birth record. Guideline I.C.16.b.1 permits Z05 only where a healthy newborn is evaluated for a suspected condition determined after study not to be present, and prohibits it where the patient is documented to have signs or symptoms — in which case the sign or symptom is coded.

Correct answer: B. Due to the birth process; use the Chapter 16 code

Rationale. Guideline I.C.16.a.5 states that if a newborn has a condition that may be either due to the birth process or community acquired and the documentation does not indicate which it is, the default is due to the birth process and the code from Chapter 16 should be used. If the condition is documented as community-acquired, a code from Chapter 16 should not be assigned.

Correct answer: B. Yes — whenever the condition is diagnosed by the provider

Rationale. Section I.C.17 states that codes from Chapter 17 may be used throughout the life of the patient, and that although present at birth a malformation, deformation, chromosomal abnormality or genetic disorder may not be identified until later in life — whenever the condition is diagnosed by the provider, it is appropriate to assign a code from categories Q00-QA1.

Correct answer: B. The abnormality code only

Rationale. Section I.C.17 states that when the code assignment specifically identifies the malformation, deformation, chromosomal abnormality or genetic disorder, manifestations that are an inherent component of the anomaly should not be coded separately, and that additional codes should be assigned for manifestations that are not an inherent component.

Correct answer: B. A code from category Z38

Rationale. Section I.C.17 states that for the birth admission the appropriate code from category Z38, liveborn infants according to place of birth and type of delivery, should be sequenced as the principal diagnosis, followed by any congenital anomaly codes in categories Q00-QA1. Section I.C.16.a.2 gives the same rule from the perinatal chapter's side.

Correct answer: B. A personal history code

Rationale. Section I.C.17 states that if a congenital malformation or deformity has been corrected, a personal history code should be used to identify the history of the malformation or deformity. Section I.C.21.c.4 explains the general principle: personal history codes explain a past medical condition that no longer exists and is not receiving treatment, but that has the potential for recurrence and may require continued monitoring.

Correct answer: B. Additional codes for any manifestations that are present

Rationale. Section I.C.17 states that when a malformation, deformation, chromosomal abnormality or genetic disorder does not have a unique code assignment, additional codes should be assigned for any manifestations that may be present. Section I.B.15 gives the parallel rule for syndromes: follow the Alphabetic Index guidance, and in its absence assign codes for the documented manifestations.

Correct answer: B. The pneumonia code only

Rationale. Section I.C.18.b states that signs or symptoms associated routinely with a disease process should not be assigned as additional codes, unless otherwise instructed by the classification. Section I.B.5 states the same rule generally. Symptoms not routinely associated with the diagnosis may be reported in addition, sequenced after the definitive diagnosis.

Correct answer: B. After the diagnosis codes, one from each subcategory, with matching 7th characters

Rationale. Section I.C.18.e.1 states that the coma scale codes can be used in conjunction with traumatic brain injury codes, that they should be sequenced after the diagnosis codes, that these codes — one from each subcategory — are needed to complete the scale, and that the 7th character indicating when the scale was recorded should match for all three codes. R40.24- is used when only the total score is documented.

Correct answer: B. The injury code, R65.11, and the code for the acute renal dysfunction

Rationale. Section I.C.18.g states that when SIRS is documented with a noninfectious condition and no subsequent infection is documented, the code for the underlying condition such as an injury should be assigned, followed by R65.10 SIRS without acute organ dysfunction or R65.11 SIRS with acute organ dysfunction, and that if an associated acute organ dysfunction is documented the appropriate codes for the specific type of organ dysfunction should be assigned in addition to R65.11.

Correct answer: A. R99

Rationale. Section I.C.18.h states that code R99, ill-defined and unknown cause of mortality, is only for use in the very limited circumstance when a patient who has already died is brought into an emergency department or other healthcare facility and is pronounced dead upon arrival, and that it does not represent the discharge disposition of death.

Correct answer: C. Both R29.6 and Z91.81

Rationale. Section I.C.18.d states that R29.6 repeated falls is for use for encounters when a patient has recently fallen and the reason for the fall is being investigated, that Z91.81 history of falling is for use when a patient has fallen in the past and is at risk for future falls, and that when appropriate both codes may be assigned together.

Correct answer: B. The appropriate initial-encounter character, because active treatment is ongoing

Rationale. Section I.C.19.a states that while the patient may be seen by a new or different provider over the course of treatment for an injury, assignment of the 7th character is based on whether the patient is undergoing active treatment and not whether the provider is seeing the patient for the first time, and that 7th character A initial encounter is used for each encounter where the patient is receiving active treatment. Section I.C.19.c.1 applies the same rule to fractures.

Correct answer: B. The appropriate complication code

Rationale. Section I.C.19.b.3 states that injury codes from Chapter 19 should not be assigned for injuries that occur during, or as a result of, a medical intervention, and that the appropriate complication code should be assigned. Section I.C.19.g.5 then directs where the complication code is found: intraoperative and postprocedural complication codes are in the body system chapters and are sequenced first.

Correct answer: B. Only the code for the third degree burn of the right thigh

Rationale. Section I.C.19.d.2 states that burns of the same anatomic site and on the same side but of different degrees are classified to the subcategory identifying the highest degree recorded in the diagnosis, and gives this exact example: for second and third degree burns of the right thigh, assign only code T24.311-. Section I.C.19.d.1 separately requires that the highest degree of burn be sequenced first where more than one burn is present.

Correct answer: B. The hypertensive emergency first, with the underdosing code T46.- with 5th or 6th character 6 and a Z91.12- noncompliance code

Rationale. Section I.C.19.e.5.c states that codes for underdosing should never be assigned as principal or first-listed codes, that if a patient has a relapse or exacerbation of the medical condition because of the reduction in dose the medical condition itself should be coded, and that noncompliance codes Z91.12-, Z91.13-, Z91.14- and Z91.A4- or complication of care codes Y63.6-Y63.9 are used with an underdosing code to indicate intent, if known. Section I.C.19.e confirms that no additional external cause code is required.

Correct answer: B. Z04.72

Rationale. Section I.C.19.f states that if a suspected case of abuse, neglect or mistreatment is ruled out during an encounter, code Z04.71 for alleged physical adult abuse ruled out or Z04.72 for alleged child physical abuse ruled out should be used, not a code from T76. Z04.42 is for alleged child rape, and Z04.81 and Z04.82 cover forced sexual and forced labour exploitation ruled out.

Correct answer: B. X37.0- hurricane

Rationale. Section I.B.19.b states that codes for cataclysmic events such as a hurricane take priority over all other external cause codes except child and adult abuse and terrorism, and should be sequenced before other external cause of injury codes, using this exact example: external cause codes for both the hurricane and the building collapse are assigned, with the hurricane code sequenced first. Section I.C.20.f sets the same hierarchy in general terms.

Correct answer: B. Accidental

Rationale. Section I.C.20.h states that if the intent — accident, self-harm, assault — of the cause of an injury or other condition is unknown or unspecified, the intent is coded as accidental, and that all transport accident categories assume accidental intent. Section I.C.20.h.1 restricts undetermined intent codes to cases where the documentation in the record specifies that the intent cannot be determined.

Correct answer: B. One

Rationale. Section I.C.20.c states that an activity code is used only once, at the initial encounter for treatment, and that only one code from Y93 should be recorded on a medical record. The activity codes are not applicable to poisonings, adverse effects, misadventures or sequela, and Y93.9 unspecified activity is not assigned if the activity is not stated.

Correct answer: C. No — the external cause and intent are included in the code

Rationale. Section I.C.20.a.8 states that no external cause code from Chapter 20 is needed if the external cause and intent are included in a code from another chapter, and gives T36.0X1- as the example. Section I.C.19.e states the same rule from the poisoning chapter's side: codes in categories T36-T65 are combination codes that include the substance and the intent, so no additional external cause code is required.

Correct answer: B. Whenever any other external cause code is assigned, including an activity code, with the stated exceptions

Rationale. Section I.C.20.k states that a code from category Y99 should be assigned whenever any other external cause code is assigned for an encounter, including an activity code, except for the noted events, and that a Y99 code should not be assigned if no other external cause codes are applicable. External cause status codes are not applicable to poisonings, adverse effects, misadventures or late effects, are used only once at the initial encounter, and only one is recorded.

Correct answer: B. A code from subcategory Z40.0

Rationale. Section I.C.21.c.13 states that for encounters specifically for prophylactic removal of an organ, such as prophylactic removal of breasts due to genetic susceptibility to cancer or a family history of cancer, the principal or first-listed code should be from subcategory Z40.0 or Z40.8, with additional codes to identify any associated risk factor such as genetic susceptibility or family history.

Correct answer: B. The follow-up code, then the history code

Rationale. Section I.C.21.c.8 states that follow-up codes are used to explain continuing surveillance following completed treatment of a disease, condition or injury, that they imply the condition has been fully treated and no longer exists, that they may be used with history codes to provide the full picture, and that the follow-up code is sequenced first, followed by the history code. If the condition is found to have recurred, the diagnosis code is assigned in place of the follow-up code.

Correct answer: B. No — this is a diagnostic examination; code the signs and symptoms

Rationale. Section I.C.21.c.5 states that screening is the testing for disease or disease precursors in seemingly well individuals, and that the testing of a person to rule out or confirm a suspected diagnosis because the patient has some sign or symptom is a diagnostic examination, not a screening — in which case the sign or symptom is used to explain the reason for the test.

Correct answer: B. No — Z79 is not for medication given for a brief period to treat an acute illness

Rationale. Section I.C.21.c.3 states that a code from Z79 is assigned if the patient is receiving a medication for an extended period as a prophylactic measure or as treatment of a chronic condition or a disease requiring a lengthy course of treatment, and that a code from category Z79 should not be assigned for medication being administered for a brief period of time to treat an acute illness or injury, using a course of antibiotics to treat acute bronchitis as the example.

Correct answer: B. Yes — code assignment may be based on documentation from clinicians involved in the patient's care who are not the provider

Rationale. Section I.C.21.c.17 states that for social determinants of health classified to chapter 21, such as categories Z55-Z65, code assignment may be based on medical record documentation from clinicians involved in the care of the patient who are not the patient's provider, since this represents social information rather than medical diagnoses, and names social workers, community health workers, case managers and nurses. Patient self-reported documentation may be used as long as it is signed off by and incorporated into the record by a clinician or provider. Section I.B.14 lists SDOH among the exceptions and restricts these codes to secondary diagnoses.

Correct answer: C. Three

Rationale. Section I.C.22 lists three codes: U07.0 vaping-related disorder, cross-referenced to Section I.C.10.e; U07.1 COVID-19, cross-referenced to Section I.C.1.g.1; and U09.9 post COVID-19 condition, unspecified, cross-referenced to Section I.C.1.g.1.m. The chapter itself contains no independent rules.

Correct answer: C. The presenting signs and symptoms

Rationale. Section I.C.1.g.1.a states that only a confirmed diagnosis of COVID-19 as documented by the provider is coded to U07.1, and that if the provider documents suspected, possible, probable or inconclusive COVID-19, U07.1 is not assigned — the signs and symptoms reported are coded instead, per guideline I.C.1.g.1.g. Z20.822 would be added if there were actual or suspected exposure.

Correct answer: B. The fatigue code and U09.9

Rationale. Section I.C.1.g.1.m states that for a sequela of COVID-19, or associated symptoms or conditions that develop following a previous infection, a code for the specific symptom or condition related to the previous infection is assigned, if known, along with U09.9 post COVID-19 condition, unspecified, and that U09.9 should not be assigned for manifestations of an active infection.

Correct answer: B. U07.0 only

Rationale. Section I.C.10.e states that for patients presenting with conditions related to vaping, U07.0 is assigned as the principal diagnosis, and that for lung injury due to vaping only code U07.0 is assigned. Additional codes are assigned for other manifestations such as acute respiratory failure or pneumonitis, but none is documented here.

Correct answer: B. O98.5-

Rationale. Section I.C.1.g.1.b states that U07.1 is sequenced first when COVID-19 meets the definition of principal diagnosis except where another guideline requires certain codes to be sequenced first, naming obstetrics, sepsis and transplant complications. Section I.C.15.s directs that during pregnancy, childbirth or the puerperium, when COVID-19 is the reason for admission, O98.5- is sequenced as the principal or first-listed diagnosis followed by U07.1 and the manifestation codes. Chapter 15 codes always take sequencing priority.

Correct answer: B. The cholelithiasis

Rationale. Section II.F states that where the original treatment plan is not carried out, the principal diagnosis is the condition which, after study, occasioned the admission to the hospital, even though treatment may not have been carried out due to unforeseen circumstances. A Z53 code may be reported additionally to explain the circumstance, but it does not displace the condition that occasioned the admission.

Correct answer: B. The medical condition which led to the hospital admission

Rationale. Section II.I.1 states that when a patient is admitted to an observation unit for a medical condition which either worsens or does not improve, and is subsequently admitted as an inpatient of the same hospital for that same medical condition, the principal diagnosis is the medical condition which led to the hospital admission. What that condition is depends on what was established after study.

Correct answer: B. The unrelated condition

Rationale. Section II.J sets out three outcomes for admission from outpatient surgery: if the reason for the inpatient admission is a complication, the complication is the principal diagnosis; if no complication or other condition is documented as the reason, the reason for the outpatient surgery is the principal diagnosis; and if the reason is another condition unrelated to the surgery, the unrelated condition is the principal diagnosis.

Correct answer: B. Code both as if confirmed; either may be sequenced first

Rationale. Section II.D states that in those rare instances when two or more contrasting or comparative diagnoses are documented as either/or, or similar terminology, they are coded as if the diagnoses were confirmed and are sequenced according to the circumstances of the admission — and that if no further determination can be made as to which should be principal, either diagnosis may be sequenced first.

Correct answer: B. S72.141D, the injury code with the 7th character for subsequent encounter

Rationale. Section II.K states that for rehabilitation services following active treatment of an injury, the injury code with the appropriate seventh character for subsequent encounter is assigned as the first-listed or principal diagnosis, and uses this exact example: rehabilitation post hip replacement for a right intertrochanteric femur fracture is reported with S72.141D. The aftercare code Z47.1 applies only where the rehabilitation does not follow an injury.

Correct answer: C. Ask the provider whether the abnormal finding should be added

Rationale. Section III.B states that abnormal findings are not coded and reported unless the provider indicates their clinical significance, and that if the findings are outside the normal range and the provider has ordered other tests to evaluate the condition or prescribed treatment, it is appropriate to ask the provider whether the abnormal finding should be added. Assigning the code from the laboratory value alone would breach Section I.A.19 as well, which bases code assignment on the provider's diagnostic statement.

Correct answer: C. At least one

Rationale. Section III defines other diagnoses as additional clinically significant conditions that affect patient care in terms of requiring clinical evaluation; or therapeutic treatment; or diagnostic procedures; or extended length of hospital stay; or increased nursing care and/or monitoring. The criteria are joined by 'or', so any one is sufficient.

Correct answer: B. Do not report it; it is coded only if required by hospital policy

Rationale. Section III.A states that some providers include in the diagnostic statement resolved conditions or diagnoses and status-post procedures from previous admissions that have no bearing on the current stay, and that such conditions are not to be reported and are coded only if required by hospital policy. The same guideline permits history codes Z80-Z87 as secondary codes where the historical condition has an impact on current care or influences treatment.

Correct answer: C. Code the urinary tract infection as if it existed or was established

Rationale. Section III.C states that if the diagnosis documented at the time of discharge is qualified as probable, suspected, likely, questionable, possible, still to be ruled out, compatible with, consistent with, or other similar terms indicating uncertainty, the condition is coded as if it existed or was established — the bases being the diagnostic workup, arrangements for further workup or observation, and the initial therapeutic approach. The guideline is applicable only to inpatient admissions to short-term, acute, long-term care and psychiatric hospitals.

Correct answer: C. Has implications for future health care needs

Rationale. Section I.C.16.a.6 lists the six criteria for clinically significant newborn conditions and notes explicitly that the perinatal guidelines are the same as the general coding guidelines for additional diagnoses except for the final point regarding implications for future health care needs. Section I.C.16.c.2 adds that this guideline should not be used for adult patients.

Correct answer: B. The heartburn symptom code

Rationale. Section IV.H states that in the outpatient setting, diagnoses documented as probable, suspected, questionable, rule out, compatible with, consistent with or working diagnosis are not coded, and the condition is coded to the highest degree of certainty for that encounter — such as symptoms, signs, abnormal test results or other reason for the visit. The guideline notes explicitly that this differs from the coding practices used by short-term, acute care, long-term care and psychiatric hospitals.

Correct answer: B. The reason for the surgery

Rationale. Section IV.A.1 states that when a patient presents for outpatient surgery, also called same day surgery, the reason for the surgery is coded as the first-listed diagnosis, even if the surgery is not performed due to a contraindication. A Z53 code may be reported additionally to explain the circumstance.

Correct answer: B. The pneumonia only

Rationale. Section IV.K states that for outpatient encounters for diagnostic tests that have been interpreted by a physician, and the final report is available at the time of coding, any confirmed or definitive diagnosis documented in the interpretation is coded, and related signs and symptoms are not coded as additional diagnoses. The guideline also notes that this differs from the coding practice in the hospital inpatient setting regarding abnormal findings on test results.

Correct answer: B. A code from subcategory Z01.81

Rationale. Section IV.M states that for patients receiving preoperative evaluations only, sequence first a code from subcategory Z01.81, encounter for pre-procedural examinations, to describe the pre-op consultations, assign a code for the condition describing the reason for the surgery as an additional diagnosis, and code also any findings related to the pre-op evaluation. Section I.C.21.c.12 adds that pre-operative examination Z codes are for use only where a patient is being cleared for a procedure and no treatment is given.

Correct answer: B. The code for general medical examination with abnormal findings

Rationale. Section IV.P states that should a general medical examination result in an abnormal finding, the code for general medical examination with abnormal finding is assigned as the first-listed diagnosis, with a secondary code for the abnormal finding. An examination with abnormal findings refers to a condition newly identified or a change in severity of a chronic condition, such as uncontrolled hypertension or an acute exacerbation of COPD, found during a routine physical examination.

Correct answer: B. Y

Rationale. Appendix I defines present on admission as present at the time the order for inpatient admission occurs, and states that conditions that develop during an outpatient encounter, including emergency department, observation or outpatient surgery, are considered as present on admission. The assigning rules repeat this: assign Y for any condition that develops during an outpatient encounter prior to a written order for inpatient admission.

Correct answer: B. N, because at least one clinical concept was not present on admission

Rationale. Appendix I, codes that contain multiple clinical concepts, directs assignment of N if at least one of the clinical concepts included in the code was not present on admission, and gives COPD with acute exacerbation where the exacerbation was not present on admission as its first worked example. Y is assigned only if all of the clinical concepts were present.

Correct answer: B. Y, because the infection or signs of it were present on admission

Rationale. Appendix I states that for infection codes that include the causal organism, Y is assigned if the infection or signs of the infection were present on admission, even though the culture results may not be known until after admission, and uses this exact example: a patient admitted with pneumonia where the provider documents Pseudomonas as the causal organism a few days later.

Correct answer: B. Y

Rationale. Appendix I states that newborns are not considered to be admitted until after birth, and therefore any condition present at birth or that developed in utero is considered present at admission and should be assigned Y — including conditions that occur during delivery, such as injury during delivery, meconium aspiration, and exposure to streptococcus B in the vaginal canal.

Correct answer: B. U, which should not be routinely assigned — query the provider

Rationale. Appendix I directs assignment of U when the medical record documentation is unclear as to whether the condition was present on admission, states that U should not be routinely assigned and should be used only in very limited circumstances, and encourages coders to query the provider when the documentation is unclear. W is reserved for the different situation where the documentation states that it cannot be clinically determined. Leaving the field blank is permitted only for codes on the exempt list.