ICD-10-CM - Chapter 3 Questions &
Answers
The term "first-listed diagnosis" is used in lieu of __________ diagnosis in an outpatient
setting - ANSWERSPrincipal
When reporting the first-listed diagnosis, the coding conventions and specific guidelines
of the ICD-10-CM take precedence over the outpatient guidelines.
True False - ANSWERSTrue
Identify the first-listed diagnosis in the following encounters or visits:
1. Established patient complaining of painful urination and frequency. Patient is a type 2
diabetic. Lab work revealed a urinary tract infection and blood glucose was within
normal limits.
2. Established patient presented to clinic with exacerbation of Crohn's disease. Patient's
rheumatoid arthritis is stable and no medication changes were made.
3. Initial office visit for sprained left knee. Patient has a history of hypertension and
asthma, both stable at this time.
4. Initial office visit for patient requiring equal management of COPD and CHF.
5. Established patient seen for cough, fever, and shortness of breath. Chest x-ray
confirmed physician's diagnosis of pneumonia and patient was sent home on antibiotics.
- ANSWERS1. urinary tract infection
2. Crohn's disease
3. sprained knee
4. COPD or CHF (either could be first-listed)
5. pneumonia
Using reference material, assign codes to the following:
1 Initial office visit for a 28-year-old male with persistent abdominal pain and bloody
diarrhea. Patient was scheduled for small-bowel x-rays and colonoscopy and will be
seen in the office following those outpatient procedures.
, 2 Follow-up office visit for a 28-year-old male with recent colonoscopy with biopsy and
small bowel x-rays. The biopsy and small bowel x-rays confirmed that the patient had
ulcerative colitis and the patient was started on sulfasalazine.
3 Initial office visit for 55-year-old male with fatigue and jaundice. Laboratory tests were
ordered and patient will return in 1 week for the results.
4 Follow-up office visit for 55-year-old male with jaundice and fatigue. Diagnostic tests
confirm that the patient has hepatitis C. He will be treated with interferon therapy. -
ANSWERS1. R10.9 (Pain, abdominal); K92.1 (Blood, in, feces). Either diagnosis could
be listed first
2. K51.90 (Colitis, ulcerative (chronic))
3. R53.83 (Fatigue); R17 (Jaundice (yellow)). Either diagnosis could be listed first.
4. B19.20 (Hepatitis C (viral))
When a patient presents for outpatient surgery, the reason for surgery should be
reported as the first-listed diagnosis. - ANSWERSTrue
Identify the first-listed diagnosis in the following:
1. A female patient was admitted as an outpatient for elective bilateral tubal ligation. The
patient was noted to be wheezing during the nurse's assessment. She was seen by her
physician and her surgery was canceled because of an exacerbation of her asthma.
2. A male patient was admitted as an outpatient for transurethral prostatic resection for
symptomatic benign prostatic hypertrophy.
3. A patient was admitted as an outpatient for a cystoscopy for hematuria. The
procedure was performed without complications. No abnormality or explanation for the
hematuria was found. - ANSWERS1. admission for elective sterilization
2. benign prostatic hypertrophy
3. hematuria
SECTION IV.B. Codes from a00.0 through t88.9, Z00-Z99, U00-U85 - ANSWERSThe
appropriate code(s) from A00.0 through T88.9, Z00-Z99 and U00-U85 must be used to
identify diagnoses, symptoms, conditions, problems, complaints, or other reason(s) for
the encounter/visit.
According to the Guidelines, which category code would you reference to report
inoculations and vaccinations? - ANSWERSZ23
According to the Guidelines, this category is referenced when reporting suspected
exposure to a communicable disease - ANSWERSZ20
Can Z codes be used only in the outpatient setting? - ANSWERSNo
Status codes - ANSWERSindicate that a patient is either a carrier of a disease or has
the sequelae or residual of a past disease or condition (Z14 - Z99)
History codes - ANSWERSindicate that the problem no longer exists
Answers
The term "first-listed diagnosis" is used in lieu of __________ diagnosis in an outpatient
setting - ANSWERSPrincipal
When reporting the first-listed diagnosis, the coding conventions and specific guidelines
of the ICD-10-CM take precedence over the outpatient guidelines.
True False - ANSWERSTrue
Identify the first-listed diagnosis in the following encounters or visits:
1. Established patient complaining of painful urination and frequency. Patient is a type 2
diabetic. Lab work revealed a urinary tract infection and blood glucose was within
normal limits.
2. Established patient presented to clinic with exacerbation of Crohn's disease. Patient's
rheumatoid arthritis is stable and no medication changes were made.
3. Initial office visit for sprained left knee. Patient has a history of hypertension and
asthma, both stable at this time.
4. Initial office visit for patient requiring equal management of COPD and CHF.
5. Established patient seen for cough, fever, and shortness of breath. Chest x-ray
confirmed physician's diagnosis of pneumonia and patient was sent home on antibiotics.
- ANSWERS1. urinary tract infection
2. Crohn's disease
3. sprained knee
4. COPD or CHF (either could be first-listed)
5. pneumonia
Using reference material, assign codes to the following:
1 Initial office visit for a 28-year-old male with persistent abdominal pain and bloody
diarrhea. Patient was scheduled for small-bowel x-rays and colonoscopy and will be
seen in the office following those outpatient procedures.
, 2 Follow-up office visit for a 28-year-old male with recent colonoscopy with biopsy and
small bowel x-rays. The biopsy and small bowel x-rays confirmed that the patient had
ulcerative colitis and the patient was started on sulfasalazine.
3 Initial office visit for 55-year-old male with fatigue and jaundice. Laboratory tests were
ordered and patient will return in 1 week for the results.
4 Follow-up office visit for 55-year-old male with jaundice and fatigue. Diagnostic tests
confirm that the patient has hepatitis C. He will be treated with interferon therapy. -
ANSWERS1. R10.9 (Pain, abdominal); K92.1 (Blood, in, feces). Either diagnosis could
be listed first
2. K51.90 (Colitis, ulcerative (chronic))
3. R53.83 (Fatigue); R17 (Jaundice (yellow)). Either diagnosis could be listed first.
4. B19.20 (Hepatitis C (viral))
When a patient presents for outpatient surgery, the reason for surgery should be
reported as the first-listed diagnosis. - ANSWERSTrue
Identify the first-listed diagnosis in the following:
1. A female patient was admitted as an outpatient for elective bilateral tubal ligation. The
patient was noted to be wheezing during the nurse's assessment. She was seen by her
physician and her surgery was canceled because of an exacerbation of her asthma.
2. A male patient was admitted as an outpatient for transurethral prostatic resection for
symptomatic benign prostatic hypertrophy.
3. A patient was admitted as an outpatient for a cystoscopy for hematuria. The
procedure was performed without complications. No abnormality or explanation for the
hematuria was found. - ANSWERS1. admission for elective sterilization
2. benign prostatic hypertrophy
3. hematuria
SECTION IV.B. Codes from a00.0 through t88.9, Z00-Z99, U00-U85 - ANSWERSThe
appropriate code(s) from A00.0 through T88.9, Z00-Z99 and U00-U85 must be used to
identify diagnoses, symptoms, conditions, problems, complaints, or other reason(s) for
the encounter/visit.
According to the Guidelines, which category code would you reference to report
inoculations and vaccinations? - ANSWERSZ23
According to the Guidelines, this category is referenced when reporting suspected
exposure to a communicable disease - ANSWERSZ20
Can Z codes be used only in the outpatient setting? - ANSWERSNo
Status codes - ANSWERSindicate that a patient is either a carrier of a disease or has
the sequelae or residual of a past disease or condition (Z14 - Z99)
History codes - ANSWERSindicate that the problem no longer exists
