AHIMA Certified Coding Specialist Physician-based (CCS-P®)
Q&A Practice Test
Domain 1 – Diagnosis Coding (ICD-10-CM)
Question 1
A patient presents to a physician office with a chief complaint of right knee pain. The
documentation states the patient has primary osteoarthritis of the right knee. Which ICD-10-CM
code is most appropriate?
A) M17.11
B) M17.12
C) M17.9
D) M25.561
Answer: A) M17.11
Rationale: M17.11 is the correct code for primary osteoarthritis of the right knee. M17.12
indicates the left knee, M17.9 is unspecified, and M25.561 is pain in the right knee but does not
capture the underlying condition. Always code the underlying condition rather than just the
symptom when the diagnosis is documented.
Question 2
Which ICD-10-CM guideline states that a code from Chapter 21 (Factors influencing health
status) should be used when a condition is documented as "present on admission"?
A) Section I, Paragraph 1
B) Section II, Paragraph 4
C) Section III, Paragraph 2
D) Section II, Paragraph 1
Answer: D) Section II, Paragraph 1
Rationale: Section II, Paragraph 1 of the Official Guidelines requires the use of Chapter 21 codes
(Z-codes) for conditions that are present on admission but not the primary reason for the
encounter.
Question 3
,A patient's chart documents "acute myocardial infarction, STEMI, anterior wall, initial episode of
care." Which code is most specific?
A) I21.01
B) I21.3
C) I21.09
D) I21.4
Answer: A) I21.01
Rationale: I21.01 = ST elevation (STEMI) myocardial infarction of anterior wall, initial episode of
care – the most specific code for the documented scenario.
Question 4
In the ICD-10-CM Alphabetic Index, the term "fracture, closed" directs the coder to:
A) Use the code for an open fracture and add a seventh character "U"
B) Locate the code in the Tabular List under "Closed fracture" and then verify laterality
C) Assign the code for "fracture, closed" without further verification
D) Use the "use additional code" note to add a code for immobilization
Answer: B) Locate the code in the Tabular List under "Closed fracture" and then verify laterality
Rationale: "Closed fracture" is an index term that requires the coder to find the specific bone,
laterality, and verify the code in the Tabular List for the correct seventh character.
Question 5
A physician documents that a patient has "hypertensive heart disease with heart failure." What
ICD-10-CM coding convention applies?
A) Code only the hypertension
B) Code only the heart failure
C) Use a combination code that includes both conditions
D) Code both conditions separately with no sequencing requirement
Answer: C) Use a combination code that includes both conditions
Rationale: ICD-10-CM guidelines specify that when a patient has both hypertensive heart
disease and heart failure, a combination code from category I11.0 should be assigned that
captures both conditions, with the heart failure type specified when documented.
Question 6
,A patient is diagnosed with type 2 diabetes mellitus with diabetic neuropathy. What is the
correct coding approach?
A) E11.9 only
B) E11.40 only
C) E11.9 and G63.2
D) E11.40 and G63.2
Answer: D) E11.40 and G63.2
Rationale: Diabetes with neuropathy requires two codes: the diabetes code with the
manifestation code. E11.40 (Type 2 diabetes mellitus with diabetic neuropathy, unspecified) and
G63.2 (Diabetic polyneuropathy) should be assigned, with the diabetes code sequenced first.
Question 7
A patient is seen for a routine physical examination. The provider documents no abnormal
findings. Which ICD-10-CM code should be assigned?
A) Z00.00
B) Z00.01
C) Z02.0
D) Z01.00
Answer: A) Z00.00
Rationale: Z00.00 is the code for encounter for general adult medical examination without
abnormal findings. Z00.01 is for with abnormal findings. Z02.0 is for encounter for examination
for admission to educational institution.
Question 8
A patient presents with a cough that has been present for three weeks. The physician
documents "acute bronchitis." What ICD-10-CM code should be assigned?
A) J20.9
B) J40
C) R05
D) J44.9
Answer: A) J20.9
Rationale: Acute bronchitis is coded to J20.9 (Acute bronchitis, unspecified). J40 is bronchitis
not specified as acute or chronic. R05 is cough. J44.9 is chronic obstructive pulmonary disease,
unspecified.
, Question 9
A patient is diagnosed with pneumonia due to COVID-19. What ICD-10-CM code should be
assigned?
A) J12.9
B) U07.1
C) J12.9 and U07.1
D) J12.82
Answer: B) U07.1
Rationale: For COVID-19 with pneumonia, U07.1 (COVID-19) is assigned as the primary code. An
additional code for the pneumonia (J12.82) should be assigned. However, U07.1 must be
sequenced first.
Question 10
A patient is being treated for a sequela of a cerebrovascular accident that occurred six months
ago. The patient now has residual aphasia. What is the correct coding approach?
A) I69.920
B) I69.320
C) I69.90
D) R47.01
Answer: A) I69.920
Rationale: I69.920 is the code for aphasia following unspecified cerebrovascular disease. For
sequelae of CVA, codes from category I69 are used to indicate the residual condition.
Question 11
The provider documents in a patient's chart that she has Alzheimer's disease. What ICD-10-CM
diagnosis code(s) is/are assigned?
A) G30.9
B) G30.9, F02.80
C) G30.9, F02.81
D) F02.80
Answer: A) G30.9
Q&A Practice Test
Domain 1 – Diagnosis Coding (ICD-10-CM)
Question 1
A patient presents to a physician office with a chief complaint of right knee pain. The
documentation states the patient has primary osteoarthritis of the right knee. Which ICD-10-CM
code is most appropriate?
A) M17.11
B) M17.12
C) M17.9
D) M25.561
Answer: A) M17.11
Rationale: M17.11 is the correct code for primary osteoarthritis of the right knee. M17.12
indicates the left knee, M17.9 is unspecified, and M25.561 is pain in the right knee but does not
capture the underlying condition. Always code the underlying condition rather than just the
symptom when the diagnosis is documented.
Question 2
Which ICD-10-CM guideline states that a code from Chapter 21 (Factors influencing health
status) should be used when a condition is documented as "present on admission"?
A) Section I, Paragraph 1
B) Section II, Paragraph 4
C) Section III, Paragraph 2
D) Section II, Paragraph 1
Answer: D) Section II, Paragraph 1
Rationale: Section II, Paragraph 1 of the Official Guidelines requires the use of Chapter 21 codes
(Z-codes) for conditions that are present on admission but not the primary reason for the
encounter.
Question 3
,A patient's chart documents "acute myocardial infarction, STEMI, anterior wall, initial episode of
care." Which code is most specific?
A) I21.01
B) I21.3
C) I21.09
D) I21.4
Answer: A) I21.01
Rationale: I21.01 = ST elevation (STEMI) myocardial infarction of anterior wall, initial episode of
care – the most specific code for the documented scenario.
Question 4
In the ICD-10-CM Alphabetic Index, the term "fracture, closed" directs the coder to:
A) Use the code for an open fracture and add a seventh character "U"
B) Locate the code in the Tabular List under "Closed fracture" and then verify laterality
C) Assign the code for "fracture, closed" without further verification
D) Use the "use additional code" note to add a code for immobilization
Answer: B) Locate the code in the Tabular List under "Closed fracture" and then verify laterality
Rationale: "Closed fracture" is an index term that requires the coder to find the specific bone,
laterality, and verify the code in the Tabular List for the correct seventh character.
Question 5
A physician documents that a patient has "hypertensive heart disease with heart failure." What
ICD-10-CM coding convention applies?
A) Code only the hypertension
B) Code only the heart failure
C) Use a combination code that includes both conditions
D) Code both conditions separately with no sequencing requirement
Answer: C) Use a combination code that includes both conditions
Rationale: ICD-10-CM guidelines specify that when a patient has both hypertensive heart
disease and heart failure, a combination code from category I11.0 should be assigned that
captures both conditions, with the heart failure type specified when documented.
Question 6
,A patient is diagnosed with type 2 diabetes mellitus with diabetic neuropathy. What is the
correct coding approach?
A) E11.9 only
B) E11.40 only
C) E11.9 and G63.2
D) E11.40 and G63.2
Answer: D) E11.40 and G63.2
Rationale: Diabetes with neuropathy requires two codes: the diabetes code with the
manifestation code. E11.40 (Type 2 diabetes mellitus with diabetic neuropathy, unspecified) and
G63.2 (Diabetic polyneuropathy) should be assigned, with the diabetes code sequenced first.
Question 7
A patient is seen for a routine physical examination. The provider documents no abnormal
findings. Which ICD-10-CM code should be assigned?
A) Z00.00
B) Z00.01
C) Z02.0
D) Z01.00
Answer: A) Z00.00
Rationale: Z00.00 is the code for encounter for general adult medical examination without
abnormal findings. Z00.01 is for with abnormal findings. Z02.0 is for encounter for examination
for admission to educational institution.
Question 8
A patient presents with a cough that has been present for three weeks. The physician
documents "acute bronchitis." What ICD-10-CM code should be assigned?
A) J20.9
B) J40
C) R05
D) J44.9
Answer: A) J20.9
Rationale: Acute bronchitis is coded to J20.9 (Acute bronchitis, unspecified). J40 is bronchitis
not specified as acute or chronic. R05 is cough. J44.9 is chronic obstructive pulmonary disease,
unspecified.
, Question 9
A patient is diagnosed with pneumonia due to COVID-19. What ICD-10-CM code should be
assigned?
A) J12.9
B) U07.1
C) J12.9 and U07.1
D) J12.82
Answer: B) U07.1
Rationale: For COVID-19 with pneumonia, U07.1 (COVID-19) is assigned as the primary code. An
additional code for the pneumonia (J12.82) should be assigned. However, U07.1 must be
sequenced first.
Question 10
A patient is being treated for a sequela of a cerebrovascular accident that occurred six months
ago. The patient now has residual aphasia. What is the correct coding approach?
A) I69.920
B) I69.320
C) I69.90
D) R47.01
Answer: A) I69.920
Rationale: I69.920 is the code for aphasia following unspecified cerebrovascular disease. For
sequelae of CVA, codes from category I69 are used to indicate the residual condition.
Question 11
The provider documents in a patient's chart that she has Alzheimer's disease. What ICD-10-CM
diagnosis code(s) is/are assigned?
A) G30.9
B) G30.9, F02.80
C) G30.9, F02.81
D) F02.80
Answer: A) G30.9
