Chapter 3: ICD-10-CM Outpatient Coding
and Reporting Guidelines Questions &
Answers
Established patient complaining of painful urination and frequency. Patient is type 2
diabetic. Lab work revealed a urinary tract infection and blood glucose was within
normal limits. What is the first-listed diagnosis? - ANSWERSUrinary tract infection
Established patient presented to clinic with exacerbation of Crohn's disease. Patient's
rheumatoid arthritis is stable and no medication changes were made. What is the first-
listed diagnosis? - ANSWERSCrohn's disease
Initial office visit for sprained left knee. Patient has a history of hypertension and
asthma, both stable at this time. What is the first-listed diagnosis? - ANSWERSSprained
knee
Initial office visit for patient requiring equal management of COPD and CHF. What is the
first-listed diagnosis? - ANSWERSCOPD or CHF
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.
What is the first-listed diagnosis? - ANSWERSPneumonia
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. Which diagnosis code(s) will be
used? - ANSWERSR10.9, K92.1
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. Which diagnosis code(s)
will be used? - ANSWERSK51.90
, 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. Which diagnosis code(s) will be
used? - ANSWERSR53.83, R17
Follow-up 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. Which
diagnosis code(s) will be used? - ANSWERSB19.20
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.
What is the first-listed diagnosis? - ANSWERSAdmission for elective sterilization
A male patient was admitted as an outpatient for transurethral prostatic resection for
symptomatic benign prostatic hypertrophy. What is the first-listed diagnosis? -
ANSWERSBenign prostatic hypertrophy
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. What is the first-listed diagnosis? - ANSWERSHematuria
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 only be used in the outpatient setting, yes or no? - ANSWERSNo
Railway accident involving derailment without antecedent collision, injuring a porter.
Which place of occurrence code is used? - ANSWERSY92.815
Motor vehicle traffic accident due to tire blowout; driver of the car was injured, initial
encounter. Which injured person code is used? - ANSWERSV48.5XXA
Driver of an ATV (off-road vehicle) is injured when he collides with a fence. Which
injured person code is used? - ANSWERSV86.595XA
Horse being ridden, rider injured, and non-motor vehicle collision, initial encounter.
Which injured person code is used? - ANSWERSV80.790A
Accident to watercraft causing other injury; occupant of small powered boat injured due
to collision, initial encounter. Which external cause code is used? -
ANSWERSV91.83XA
A person who has been in contact with smallpox.
and Reporting Guidelines Questions &
Answers
Established patient complaining of painful urination and frequency. Patient is type 2
diabetic. Lab work revealed a urinary tract infection and blood glucose was within
normal limits. What is the first-listed diagnosis? - ANSWERSUrinary tract infection
Established patient presented to clinic with exacerbation of Crohn's disease. Patient's
rheumatoid arthritis is stable and no medication changes were made. What is the first-
listed diagnosis? - ANSWERSCrohn's disease
Initial office visit for sprained left knee. Patient has a history of hypertension and
asthma, both stable at this time. What is the first-listed diagnosis? - ANSWERSSprained
knee
Initial office visit for patient requiring equal management of COPD and CHF. What is the
first-listed diagnosis? - ANSWERSCOPD or CHF
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.
What is the first-listed diagnosis? - ANSWERSPneumonia
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. Which diagnosis code(s) will be
used? - ANSWERSR10.9, K92.1
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. Which diagnosis code(s)
will be used? - ANSWERSK51.90
, 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. Which diagnosis code(s) will be
used? - ANSWERSR53.83, R17
Follow-up 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. Which
diagnosis code(s) will be used? - ANSWERSB19.20
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.
What is the first-listed diagnosis? - ANSWERSAdmission for elective sterilization
A male patient was admitted as an outpatient for transurethral prostatic resection for
symptomatic benign prostatic hypertrophy. What is the first-listed diagnosis? -
ANSWERSBenign prostatic hypertrophy
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. What is the first-listed diagnosis? - ANSWERSHematuria
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 only be used in the outpatient setting, yes or no? - ANSWERSNo
Railway accident involving derailment without antecedent collision, injuring a porter.
Which place of occurrence code is used? - ANSWERSY92.815
Motor vehicle traffic accident due to tire blowout; driver of the car was injured, initial
encounter. Which injured person code is used? - ANSWERSV48.5XXA
Driver of an ATV (off-road vehicle) is injured when he collides with a fence. Which
injured person code is used? - ANSWERSV86.595XA
Horse being ridden, rider injured, and non-motor vehicle collision, initial encounter.
Which injured person code is used? - ANSWERSV80.790A
Accident to watercraft causing other injury; occupant of small powered boat injured due
to collision, initial encounter. Which external cause code is used? -
ANSWERSV91.83XA
A person who has been in contact with smallpox.
