CCS Domain 2 Questions & Answers
A coding professional has noted that a particular nurse practitioner is sending orders for
outpatient testing with the diagnosis listed as "possible" or "rule out" without any
accompanying signs or symptoms or abnormal findings suggestive of the possible
diagnosis. What action should the coding professional take? - ANSWERSAsk for
outpatient CDI specialist to educate the NP on the guidelines for outpatient coding
which do not permit the use of "possible" or "rule out" diagnoses.
23-year-old female is admitted for shock following treatment of an ectopic pregnancy.
This encounter would be coded as: - ANSWERSO08.3, Complication following ectopic
and molar pregnancies
When a patient is admitted and a discrepancy is noted in the documentation while the
patient is still on the unit, who is responsible for obtaining clarity on the information? -
ANSWERSThe clinical documentation specialist
The role of a clinical documentation improvement specialist (CDI) is to educate
physicians to help improve the documentation in the healthcare record
The physician inserts a speculum into the vagina to view the cervix. The cervix was
dilated. The endometrial lining of the uterus is scraped on all sides for therapeutic
purposes. What code should be assigned? - ANSWERS0UDB7ZZ
The root operation of "Extraction" is defined as pulling or stripping out or off all or a
portion of a body part. In the ICD-10-PCS definitions, dilatation and curettage is given
as an example for the root operation Extraction. Also, during a D&C a curette is used to
scrape the lining of the uterus. The Alphabetic Index main term is Extraction,
Endometrium 0UDB. Since the procedure is done for therapeutic purposes and not
diagnostic, the final character is Z
An operative report indicates the physician performed metatarsal surgery but all other
information in the health record points to need for metacarpal surgery. What step should
, the coding professional take upon this discovery? - ANSWERSQuery the physician to
determine which body area the surgery involved.
A patient record has documentation of esophageal varices. Which condition, if related,
would affect coding? - ANSWERSLiver disease
Esophageal varices are often associated with cirrhosis of the liver. If documented, dual
coding is required with the underlying condition coded first
The physician removes all of a right thyroid lobe without isthmusectomy. The physician
exposes the thyroid via a transverse cervical incision in the skin line. The platysmas are
divided and the strap muscles separated in the midline. The thyroid lobe to be excised
is isolated and superior and inferior thyroid vessels serving that lobe are ligated.
Parathyroid glands are preserved. The thyroid gland is divided in the midline of the
isthmus over the anterior trachea. The thyroid lobe is resected. The platysmas and skin
are closed. What code should be assigned? - ANSWERS0GTH0ZZ
The correct root operation for this procedure is Resection because the right lobe of the
thyroid gland has its own body part value in ICD-10-PCS and the entire body part was
removed. The procedure was performed by an Open approach.
A patient was admitted directly from his primary physician's office due to suspected
avian influenza. The admitting physician documentation indicated suspected avian
influenza, along with signs and symptoms of avian influenza. The patient left against
medical advice (AMA) before confirmatory lab tests could be drawn to identify the virus.
The principal diagnosis should be coded from category: - ANSWERSJ11, Influenza due
to unidentified influenza virus
If the provider records "suspected" or "possible" or "probable" avian influenza, or novel
influenza, or other identified influenza, then the appropriate influenza code from
category J11, Influenza due to unidentified influenza virus, should be assigned. A code
from category J09, Influenza due to certain identified influenza viruses, should not be
assigned nor should a code from category J10, Influenza due to other identified
influenza virus when the provider documents the influenza type as "suspected,"
"probable," or "possible"
A 78-year-old patient is admitted with shortness of breath and a chest x-ray reveals
infiltrates in the lung with pleural effusion. The patient also has a history of hypertension
with left ventricular hypertrophy. The patient is given Lasix and the shortness of breath
is relieved. From the information given, what is the probable principal diagnosis? -
ANSWERSCongestive heart failure
The patient has underlying symptoms specific to CHF (hypertension/ventricular
hypertrophy) and Lasix was effective in relieving the SOB. Also, congestive heart failure
includes symptoms such as shortness of breath and pleural effusion. Taken together,
this indicates that congestive heart failure is the probable principal diagnosis
A coding professional has noted that a particular nurse practitioner is sending orders for
outpatient testing with the diagnosis listed as "possible" or "rule out" without any
accompanying signs or symptoms or abnormal findings suggestive of the possible
diagnosis. What action should the coding professional take? - ANSWERSAsk for
outpatient CDI specialist to educate the NP on the guidelines for outpatient coding
which do not permit the use of "possible" or "rule out" diagnoses.
23-year-old female is admitted for shock following treatment of an ectopic pregnancy.
This encounter would be coded as: - ANSWERSO08.3, Complication following ectopic
and molar pregnancies
When a patient is admitted and a discrepancy is noted in the documentation while the
patient is still on the unit, who is responsible for obtaining clarity on the information? -
ANSWERSThe clinical documentation specialist
The role of a clinical documentation improvement specialist (CDI) is to educate
physicians to help improve the documentation in the healthcare record
The physician inserts a speculum into the vagina to view the cervix. The cervix was
dilated. The endometrial lining of the uterus is scraped on all sides for therapeutic
purposes. What code should be assigned? - ANSWERS0UDB7ZZ
The root operation of "Extraction" is defined as pulling or stripping out or off all or a
portion of a body part. In the ICD-10-PCS definitions, dilatation and curettage is given
as an example for the root operation Extraction. Also, during a D&C a curette is used to
scrape the lining of the uterus. The Alphabetic Index main term is Extraction,
Endometrium 0UDB. Since the procedure is done for therapeutic purposes and not
diagnostic, the final character is Z
An operative report indicates the physician performed metatarsal surgery but all other
information in the health record points to need for metacarpal surgery. What step should
, the coding professional take upon this discovery? - ANSWERSQuery the physician to
determine which body area the surgery involved.
A patient record has documentation of esophageal varices. Which condition, if related,
would affect coding? - ANSWERSLiver disease
Esophageal varices are often associated with cirrhosis of the liver. If documented, dual
coding is required with the underlying condition coded first
The physician removes all of a right thyroid lobe without isthmusectomy. The physician
exposes the thyroid via a transverse cervical incision in the skin line. The platysmas are
divided and the strap muscles separated in the midline. The thyroid lobe to be excised
is isolated and superior and inferior thyroid vessels serving that lobe are ligated.
Parathyroid glands are preserved. The thyroid gland is divided in the midline of the
isthmus over the anterior trachea. The thyroid lobe is resected. The platysmas and skin
are closed. What code should be assigned? - ANSWERS0GTH0ZZ
The correct root operation for this procedure is Resection because the right lobe of the
thyroid gland has its own body part value in ICD-10-PCS and the entire body part was
removed. The procedure was performed by an Open approach.
A patient was admitted directly from his primary physician's office due to suspected
avian influenza. The admitting physician documentation indicated suspected avian
influenza, along with signs and symptoms of avian influenza. The patient left against
medical advice (AMA) before confirmatory lab tests could be drawn to identify the virus.
The principal diagnosis should be coded from category: - ANSWERSJ11, Influenza due
to unidentified influenza virus
If the provider records "suspected" or "possible" or "probable" avian influenza, or novel
influenza, or other identified influenza, then the appropriate influenza code from
category J11, Influenza due to unidentified influenza virus, should be assigned. A code
from category J09, Influenza due to certain identified influenza viruses, should not be
assigned nor should a code from category J10, Influenza due to other identified
influenza virus when the provider documents the influenza type as "suspected,"
"probable," or "possible"
A 78-year-old patient is admitted with shortness of breath and a chest x-ray reveals
infiltrates in the lung with pleural effusion. The patient also has a history of hypertension
with left ventricular hypertrophy. The patient is given Lasix and the shortness of breath
is relieved. From the information given, what is the probable principal diagnosis? -
ANSWERSCongestive heart failure
The patient has underlying symptoms specific to CHF (hypertension/ventricular
hypertrophy) and Lasix was effective in relieving the SOB. Also, congestive heart failure
includes symptoms such as shortness of breath and pleural effusion. Taken together,
this indicates that congestive heart failure is the probable principal diagnosis
