AAPC CPC Coding Guidelines| Practice Exam Q&A 2025| Reviewed

AAPC CPC Coding Guidelines| Practice Exam Q&A 2025| Reviewed Finding the main diagnosis term: When searching for a diagnosis, try reading it from right to left. For example: COPD (chronic obstructive pulmonary disease) can be found under "disease" and "obstruction." URI (upper respiratory infection) is listed under "infection." Always code to the highest specificity: For example, for age-related osteoporosis with a current fracture of the left shoulder on a followup visit: M80.012D: - M80 (osteoporosis with a current fracture) - M80.0 (age-related) - M80.012 (age-related with a current fracture of the left shoulder) - M80.012D (subsequent visit) Outpatient visits: Suspected diagnoses should **never** be coded. If a definitive diagnosis is not available, code: 1. Signs 2 2. Symptoms 3. Abnormal test results Terms related to suspected diagnoses include: Probable Suspected Questionable Rule Out Differential Working Inpatient visits: Suspected diagnoses **may** be coded, except for HIV. HIV must be confirmed before it is coded. Symptoms that are integral to a disease: Symptoms that are inherent to a disease **do not** need to be coded separately. For example: A patient with severe abdominal pain, nausea, and vomiting diagnosed with acute appendicitis should only have acute appendicitis (K35.80) coded. Symptoms that are not integral to a disease: Symptoms that are not part of the disease **must** be coded separately. 3 For example: If a patient presents with a runny nose, cough, and right shoulder pain, and is diagnosed with URI, both URI and right shoulder pain should be coded: URI: J06.9 Right shoulder pain: M25.511 Multiple coding for a single condition: Certain diseases require multiple codes to capture both the etiology and manifestation. These codes will be listed in the alphabetic index with one code followed by another in brackets. For example: Amyloid heart disease would be coded as E85.4 [I43], where both the etiology and manifestation are needed. Acute and chronic conditions documented simultaneously: When both conditions are documented, code the acute condition first, then the chronic condition. For example: - Acute cystitis: N30.00 (without hematuria) - Chronic cystitis: N30.20 (without hematuria)