Latest CPC ® Certified Professional Coder Certified |SCENARIOS|–Question and Answers [100% Correct] 2025/2026

Latest CPC ® Certified Professional Coder Certified |SCENARIOS|–Question and Answers [100% Correct] 2025/2026 You are coding for a patient who has a diagnosis of acute myocardial infarction (MI), and the physician also documents the patient has developed a complication of congestive heart failure (CHF) due to the MI. What is the correct coding procedure? Code for the acute myocardial infarction first, followed by the congestive heart failure code as a secondary condition. A patient is admitted for a laparoscopic cholecystectomy. During the procedure, the surgeon converts to an open cholecystectomy due to complications. How should you code this scenario? The correct code would be for an open cholecystectomy, as this is the more invasive procedure performed. If a patient presents with a primary diagnosis of Type 2 diabetes mellitus and is also being treated for hypertension during the same visit, how should you code this situation? Code both the Type 2 diabetes mellitus as the primary diagnosis and hypertension as the secondary diagnosis, with the appropriate ICD-10 codes. You are tasked with coding a patient who had a total hip replacement surgery. The surgeon documents both the procedure and a post-operative complication of deep vein thrombosis (DVT). How should these diagnoses be coded? The total hip replacement should be coded first, followed by deep vein thrombosis as a complication, according to the guidelines for post-operative conditions. In the case of a patient admitted for pneumonia and is also noted to have a history of smoking. How should the coder proceed with sequencing these diagnoses? Pneumonia should be coded as the primary diagnosis, followed by the history of smoking as a secondary condition. However, smoking-related codes are used when smoking is a contributing factor to the disease. 1 You are coding for a patient diagnosed with an upper respiratory infection (URI) and also noted to have a history of asthma. How should these conditions be sequenced in the medical record? The upper respiratory infection should be coded as the primary diagnosis, with asthma coded second as a history condition. A physician performs a routine mammogram on a patient, and the results indicate a benign breast mass that requires a biopsy. How should you code for the biopsy? You should code for the mammogram with the diagnosis of a benign breast mass, and also code for the biopsy procedure performed for further investigation. A patient with a diagnosis of chronic back pain is treated for an acute exacerbation of the condition. How should you report the codes? Code for the acute exacerbation of back pain as the primary diagnosis, followed by the chronic back pain diagnosis as a secondary condition. When a patient is admitted for a routine procedure and the surgeon documents a complication that leads to further surgery, how should this be coded? The complication should be coded as the reason for the additional procedure, followed by the original procedure as secondary. A patient is diagnosed with a chronic condition that is being treated as part of their overall care. They also present with an acute illness that needs immediate attention. How should you approach coding for this scenario? The acute illness should be coded as the primary diagnosis, with the chronic condition as a secondary diagnosis. A patient is seen for a routine office visit and is also being treated for depression. The physician documents the depression as stable. How should the coder sequence these diagnoses? The routine office visit should be coded first, followed by depression as a secondary diagnosis with the modifier indicating it is stable. You are coding for a patient who has undergone a laparotomy for bowel obstruction and develops an infection post-operation. How should you code this scenario? 2 You should code for the bowel obstruction as the primary diagnosis and then the post-operative infection as a complication, following the guidelines for post-operative care. In a case where a patient is undergoing treatment for both rheumatoid arthritis and an unrelated non arthritic condition, how should you report these conditions? You should code for rheumatoid arthritis as the primary diagnosis if it is the reason for the visit, followed by the secondary, unrelated condition. A patient presents with a diagnosis of acute appendicitis. During the appendectomy, the surgeon also f inds and removes a small cyst on the ovary. How should these conditions be coded? Appendicitis should be coded first, with the ovarian cyst coded second as an incidental finding during the procedure. You are coding for a patient diagnosed with a history of breast cancer but is currently receiving treatment for a urinary tract infection (UTI). How should the coder sequence these conditions? The urinary tract infection should be coded as the primary diagnosis, with a history of breast cancer coded second. A physician documents a patient with suspected acute appendicitis. During the surgery, it is confirmed that the diagnosis was incorrect, and the issue is actually a gastrointestinal obstruction. How should this scenario be coded? The gastrointestinal obstruction should be coded, and the appendicitis should not be coded since it was ruled out during the surgery. When a patient is admitted for a surgical procedure but develops a complication that extends their hospital stay, how should you approach coding for this scenario? You should code for the surgery as the primary procedure and then code for the complication as a secondary diagnosis, along with the lengthened hospital stay. A patient comes in for an annual check-up and also mentions persistent lower back pain that has been ongoing for several weeks. How should you code for this visit? You should code for the annual check-up as the primary diagnosis, with the lower back pain as a secondary condition. 3 A patient is admitted for a routine follow-up after a heart bypass surgery. The physician documents that the surgery is healing well, but the patient has new complaints of leg swelling. How should this be coded? The follow-up for heart bypass should be coded first, followed by leg swelling as a secondary diagnosis if it is a new complaint. A patient with a diagnosis of schizophrenia is admitted for a routine psychiatric evaluation. They also report significant weight loss over the last few weeks. How should the coder handle this? Schizophrenia should be coded as the primary diagnosis, with weight loss as a secondary condition, reflecting the new symptom. A patient presents for a scheduled follow-up visit after a stroke. The physician documents that the patient's condition is stable but mentions new complaints of difficulty swallowing. How should you code this? The stroke should be coded first, followed by the difficulty swallowing as a secondary diagnosis. A patient is seen for a routine check-up and is diagnosed with acute bronchitis. The physician also documents a history of asthma. How should these diagnoses be handled? Acute bronchitis should be coded as the primary diagnosis, with asthma as a secondary condition. A patient is seen for a routine follow-up for hypertension and is found to have a new diagnosis of hyperlipidemia. How should the coder proceed? Hypertension should be coded first, with hyperlipidemia as a secondary diagnosis. A patient undergoes a hip replacement, and the physician documents post-operative complications of wound infection. How should the procedure and complications be coded? Code for the hip replacement procedure as the primary diagnosis, followed by the wound infection as a post-operative complication. A patient presents with a suspected diagnosis of pneumonia, but after further evaluation, it is determined to be bronchitis. How should you proceed with coding? 4 5 Code for bronchitis as the primary diagnosis, as it is the confirmed condition after evaluation. A patient with a history of lung cancer presents with a cough. The physician documents a new diagnosis of pneumonia. How should these diagnoses be coded? Pneumonia should be coded as the primary diagnosis, with a history of lung cancer as a secondary condition. During a routine office visit, a patient reports abdominal pain and is diagnosed with a peptic ulcer. How should these conditions be coded? The peptic ulcer should be coded as the primary diagnosis, with abdominal pain coded as a secondary symptom. A patient with chronic kidney disease is seen for a routine check-up and is also diagnosed with a urinary tract infection (UTI). How should these diagnoses be handled? Chronic kidney disease should be coded first, followed by the urinary tract infection as a secondary diagnosis. A patient with a history of atrial fibrillation presents for a follow-up visit after a recent stroke. How should you code this scenario? Code for the stroke as the primary diagnosis, with atrial fibrillation as a secondary condition. You are coding for a patient with a diagnosis of diabetes mellitus type 2, who also presents with a wound infection. How should these conditions be sequenced? Diabetes mellitus type 2 should be coded as the primary diagnosis, followed by the wound infection as a secondary condition. A patient undergoes a diagnostic colonoscopy due to complaints of rectal bleeding. During the procedure, a benign polyp is removed. How should this be coded? The colonoscopy should be coded with the diagnosis of rectal bleeding, and the removal of the benign polyp should be coded as an additional procedure. A patient presents with severe chest pain and is diagnosed with acute myocardial infarction (MI). The physician also notes that the patient has a history of smoking. How should you code this? Acute myocardial infarction should be coded as the primary diagnosis, with smoking as a secondary condition. A patient with a history of stroke presents for a routine visit. The physician documents that the patient is doing well but has developed new symptoms of dizziness. How should these conditions be handled? The history of stroke should be coded as a secondary condition, with dizziness as the primary diagnosis if it is the reason for the visit. A patient is admitted for a planned cholecystectomy. During the surgery, a gallbladder polyp is discovered and removed. How should these conditions be coded? The cholecystectomy should be coded as the primary procedure, with the removal of the gallbladder polyp as a secondary procedure. A patient presents for a follow-up visit after undergoing knee surgery. The physician documents that the patient is healing well but is experiencing ongoing pain. How should this scenario be coded? The knee surgery should be coded as the primary diagnosis, with ongoing pain as a secondary symptom or condition. A patient presents for a routine physical exam and is diagnosed with hypertension. The physician also notes that the patient has a history of hyperlipidemia. How should these diagnoses be handled? Hypertension should be coded as the primary diagnosis, with hyperlipidemia as a secondary condition. A patient is seen for a routine check-up and is diagnosed with a skin rash. The physician also notes a history of eczema. How should this scenario be coded? 6 The skin rash should be coded as the primary diagnosis, with eczema as a secondary condition. A patient presents with complaints of shortness of breath. After further testing, the physician diagnoses congestive heart failure. How should these conditions be coded? Congestive heart failure should be coded as the primary diagnosis, with shortness of breath as a secondary symptom. A patient is undergoing a diagnostic procedure for a suspected lung mass. The physician documents that the patient has a history of smoking. How should you code this? The suspected lung mass should be coded as the primary diagnosis, with smoking as a secondary condition if it is considered a contributing factor. A patient presents with fatigue and is diagnosed with anemia. The physician also notes a history of chronic kidney disease. How should these diagnoses be handled? Anemia should be coded as the primary diagnosis, with chronic kidney disease as a secondary condition. A patient presents with abdominal pain and is diagnosed with appendicitis. The physician also documents that the patient has a history of gallstones. How should these conditions be coded? Appendicitis should be coded as the primary diagnosis, with gallstones as a secondary condition if it is relevant to the patient’s medical history. A patient with diabetes mellitus type 1 presents for a routine check-up. The physician documents that the patient's diabetes is well-controlled, but the patient is also experiencing neuropathy. How should this be coded? 7 8 Diabetes mellitus type 1 should be coded as the primary diagnosis, with neuropathy as a secondary condition. A patient presents with complaints of blurred vision. The physician diagnoses cataracts. How should this scenario be coded? Cataracts should be coded as the primary diagnosis, with blurred vision as a secondary symptom or manifestation. A patient presents for a routine follow-up after undergoing a hip replacement. The physician documents that the surgical site is healing well, but the patient is also experiencing back pain. How should you code this? The hip replacement should be coded as the primary diagnosis, with back pain as a secondary symptom. A patient presents for a routine wellness exam and is found to have high cholesterol. The physician also documents a history of coronary artery disease. How should these diagnoses be handled? High cholesterol should be coded as the primary diagnosis, with coronary artery disease as a secondary condition. A patient is admitted for a scheduled C-section delivery. The physician also documents that the patient has gestational diabetes. How should these conditions be handled? The C-section should be coded as the primary procedure, with gestational diabetes as a secondary condition. A patient presents with complaints of leg swelling and is diagnosed with deep vein thrombosis (DVT). The physician also notes that the patient has a history of hypertension. How should you code this? Deep vein thrombosis should be coded as the primary diagnosis, with hypertension as a secondary condition. A patient presents for a routine check-up and is found to have a mild upper respiratory infection (URI). The physician also notes a history of asthma. How should this be coded? Upper respiratory infection should be coded as the primary diagnosis, with asthma as a secondary condition. A patient is seen for a routine follow-up after a hip replacement and is also found to have a urinary tract infection (UTI). How should these conditions be handled? The hip replacement should be coded as the primary diagnosis, with the urinary tract infection as a secondary diagnosis. A patient presents with symptoms of shortness of breath and is diagnosed with asthma. The physician also notes a history of heart disease. How should this be coded? Asthma should be coded as the primary diagnosis, with heart disease as a secondary condition. A patient is seen for a scheduled routine visit and is diagnosed with hypertension and hyperlipidemia. How should these diagnoses be handled? Hypertension should be coded as the primary diagnosis, with hyperlipidemia as a secondary diagnosis. A patient is admitted for a scheduled heart bypass surgery. The physician documents a history of diabetes and high blood pressure. How should these conditions be handled? The heart bypass surgery should be coded as the primary procedure, with diabetes and high blood pressure as secondary conditions. A patient presents for a routine physical and is found to have a mild ear infection. The physician also documents that the patient has a history of allergies. How should this scenario be coded? 9 Ear infection should be coded as the primary diagnosis, with a history of allergies as a secondary condition. A patient presents for a scheduled mammogram and is diagnosed with a breast lump. The physician also notes a history of breast cancer. How should these diagnoses be handled? The breast lump should be coded as the primary diagnosis, with the history of breast cancer as a secondary condition. A patient is admitted for an urgent appendectomy. During the procedure, the physician discovers that the patient has a history of diverticulitis. How should you code this? Appendectomy should be coded as the primary procedure, with a history of diverticulitis as a secondary diagnosis. A patient presents for a follow-up visit after knee surgery and is found to have a mild post-surgical infection. How should these conditions be coded? The knee surgery should be coded as the primary diagnosis, with the post-surgical infection as a secondary condition. A patient is seen for a routine follow-up after an open heart surgery. The physician documents that the patient is recovering well but has developed some post-operative swelling. How should these conditions be handled? The open heart surgery should be coded as the primary diagnosis, with post-operative swelling as a secondary condition. A patient presents with a cough and is diagnosed with chronic bronchitis. The physician also notes that the patient has a history of smoking. How should these diagnoses be handled? 10 11 Chronic bronchitis should be coded as the primary diagnosis, with smoking as a secondary condition. A patient presents with persistent headaches and is diagnosed with chronic migraine. The physician also documents that the patient has a history of depression. How should these conditions be handled? Chronic migraine should be coded as the primary diagnosis, with depression as a secondary condition. A patient presents for a routine physical exam and is diagnosed with type 2 diabetes. The physician also notes a history of high blood pressure. How should these diagnoses be coded? Type 2 diabetes should be coded as the primary diagnosis, with high blood pressure as a secondary condition. A patient is admitted for a scheduled knee replacement surgery. The physician documents that the patient has a history of osteoarthritis. How should these conditions be handled? Knee replacement surgery should be coded as the primary procedure, with osteoarthritis as a secondary condition. A patient is admitted for a procedure related to diverticulitis. Post-operation, the patient develops a urinary tract infection (UTI). How should you code this? Diverticulitis should be coded as the primary diagnosis, with the urinary tract infection as a secondary complication. A patient presents for a scheduled procedure for a cataract removal, but during the examination, the physician finds signs of diabetic retinopathy. How should you proceed? Cataract removal should be coded as the primary procedure, with diabetic retinopathy as a secondary diagnosis. A patient is admitted for a gallbladder surgery. The physician documents that the patient also has a history of hypertension. How should these conditions be coded? 12 The gallbladder surgery should be coded first, with hypertension as a secondary diagnosis. A patient is diagnosed with chronic migraine and is also noted to have a history of depression. How should these diagnoses be handled? Chronic migraine should be coded as the primary diagnosis, with depression as a secondary condition. A patient is seen for a routine check-up, and the physician documents that the patient has a history of stroke. How should this be coded? The history of stroke should be coded as a secondary diagnosis if it is not contributing to the current visit. A patient has a diagnosed urinary tract infection (UTI) and is also noted to have an unrelated history of hypertension. How should these conditions be sequenced? The urinary tract infection should be coded as the primary diagnosis, with hypertension as a secondary condition. A patient is undergoing a routine colonoscopy for colorectal cancer screening and is also being treated for chronic constipation. How should this scenario be coded? Colonoscopy should be coded first for screening, followed by chronic constipation as a secondary condition. A patient presents for a follow-up visit after undergoing a hip replacement. The physician notes that the patient has developed an infection at the surgical site. How should these conditions be coded? The hip replacement should be coded as the primary diagnosis, followed by the surgical site infection as a secondary condition. A patient presents with chest pain, and after further testing, it is determined that the cause is acid reflux disease. How should this scenario be coded? Acid reflux disease should be coded as the primary diagnosis, with chest pain as a symptom or secondary diagnosis. A patient with a history of hypertension presents with a new diagnosis of congestive heart failure. How should these diagnoses be sequenced? Congestive heart failure should be coded as the primary diagnosis, with hypertension as a secondary condition. A patient presents for a routine follow-up after a hysterectomy. The physician documents that the patient has a history of anemia but is not currently being treated for it. How should these conditions be coded? The hysterectomy should be coded first, with a history of anemia as a secondary condition if relevant. A patient is seen for a routine wellness exam and is diagnosed with hyperglycemia. The physician also notes that the patient has a history of diabetes. How should this be handled? Hyperglycemia should be coded as the primary diagnosis, with a history of diabetes coded as a secondary condition. A patient presents with signs of dehydration and is found to have acute renal failure. How should these diagnoses be coded? Acute renal failure should be coded as the primary diagnosis, with dehydration as a secondary condition. A patient is seen for a routine visit and is diagnosed with seasonal allergies. The physician also documents a history of asthma. How should these conditions be handled? 13 14 Seasonal allergies should be coded as the primary diagnosis, with asthma as a secondary condition. A patient is admitted for a planned knee surgery. During the procedure, it is discovered that the patient also has a meniscal tear. How should you code this? The knee surgery should be coded first, with the meniscal tear as a secondary diagnosis. A patient is seen for a routine check-up and is diagnosed with hypertension. The physician also documents a history of stroke. How should these diagnoses be sequenced? Hypertension should be coded as the primary diagnosis, with the history of stroke as a secondary diagnosis. A patient is seen for a follow-up after undergoing an appendectomy. The physician documents that the patient is recovering well but also has a history of gallstones. How should this be coded? Appendectomy should be coded as the primary diagnosis, with gallstones as a secondary condition. A patient presents with a cough and is diagnosed with pneumonia. The physician also notes that the patient has a history of asthma. How should these conditions be sequenced? Pneumonia should be coded as the primary diagnosis, with asthma as a secondary condition. A patient is admitted for a hernia repair, and post-operative complications include a wound infection. How should this be coded? Hernia repair should be coded as the primary procedure, with the wound infection as a post operative complication. A patient is seen for a routine follow-up visit after an appendectomy. The physician documents that the surgical site is healing well but the patient is also experiencing constipation. How should you code this? The appendectomy follow-up should be coded first, with constipation as a secondary condition. A patient is undergoing a diagnostic workup for abnormal liver function tests. The physician documents that the patient has a history of alcohol use. How should this be coded? Abnormal liver function tests should be coded as the primary diagnosis, with alcohol use as a secondary condition if it is related to the current diagnosis. A patient presents with a persistent cough and is diagnosed with acute bronchitis. The physician also notes that the patient has a history of smoking. How should these diagnoses be handled? Acute bronchitis should be coded as the primary diagnosis, with a history of smoking as a secondary condition. A patient presents for a routine office visit and is diagnosed with a skin infection. The physician also documents that the patient has a history of diabetes. How should this be coded? The skin infection should be coded as the primary diagnosis, with diabetes as a secondary condition. A patient presents for a scheduled colonoscopy, and during the procedure, a polyp is removed. The physician also notes a history of colorectal cancer. How should this be coded? The colonoscopy procedure should be coded first, followed by the removal of the polyp and the history of colorectal cancer. A patient is admitted for surgery and has a diagnosis of chronic obstructive pulmonary disease (COPD). During the admission, the physician documents that the patient also has a history of heart disease. How should this be coded? 15 16 COPD should be coded as the primary diagnosis, with heart disease as a secondary condition. A patient with a history of breast cancer presents for a follow-up visit after a recent chemotherapy session. The physician notes that the patient's cancer is in remission. How should this be coded? Breast cancer should be coded as a history condition with remission status documented, and the follow-up visit should be coded as the primary reason for the visit. A patient presents for an annual physical exam and is found to have hypertension. The physician also notes a history of kidney disease. How should these conditions be handled? Hypertension should be coded as the primary diagnosis, with kidney disease as a secondary condition. You are coding for a patient undergoing a colonoscopy after presenting with rectal bleeding. During the procedure, a biopsy is taken of a suspected malignant area. How should this scenario be coded? You should code for the colonoscopy with the diagnosis of rectal bleeding, and then the biopsy of the suspected malignant area should be coded separately. A physician performs an excision of a benign skin lesion, and the patient is also diagnosed with a non related upper respiratory infection. How should this scenario be coded? The excision of the benign skin lesion should be coded first, with the upper respiratory infection as a secondary condition. In a case where a patient is admitted for a routine procedure and the surgeon documents a complication that leads to further surgery, how should this be coded? The complication should be coded as the reason for the additional procedure, followed by the original procedure as secondary. A patient has diabetes and is receiving insulin. During a routine visit, they also report symptoms of fatigue and are diagnosed with hypothyroidism. How should these conditions be coded? Diabetes should be coded as the primary diagnosis, with hypothyroidism as a secondary condition, reflecting the new diagnosis. If a patient has a documented history of an illness, but the condition is not actively being treated or addressed during the visit, should it still be coded? A history of illness can be coded if it impacts the current care, but if it does not contribute to the visit, it should not be coded as a primary diagnosis. A patient presents for a scheduled follow-up after a heart bypass surgery. The physician documents that the surgery is healing well, but the patient has new complaints of leg swelling. How should this be coded? The follow-up for heart bypass should be coded first, followed by leg swelling as a secondary diagnosis if it is a new complaint. 17