Medical Coding| Comprehensive Study
Guide Exam Q&A| Latest Update 2025
During an outpatient clinic visit, the physician documents a primary diagnosis of diabetes with
complications involving retinopathy. Which code should the medical coder assign to capture both
the primary condition and its specific complication?
Diabetes with retinopathy code (assign based on specific ICD code set for diabetic
complications)
A coder receives a report where a procedure was performed on both knees for a patient with
bilateral knee osteoarthritis. How should the coder indicate that both knees were treated?
Use modifiers (e.g., modifier -50 for bilateral procedures) or assign separate procedure codes
for each knee, depending on payer guidelines
If a coder is assigning codes for a patient with suspected pneumonia but no confirmed diagnosis
was provided by the end of the visit, how should they code the condition?
Code based on the patient’s symptoms and clinical findings, as confirmed diagnoses are
required for coding
1
,A patient undergoes a surgery where multiple procedures are performed in one operative session.
How should a coder approach sequencing these codes?
List the most complex or primary procedure first, followed by additional codes for secondary
procedures, using any necessary modifiers
The physician notes a complication due to a previously implanted medical device. What coding
step should the coder take to reflect this complication?
Use the appropriate ICD code for complications of the device, referencing specific code
categories for implanted device issues
How should a coder document a scenario where a patient had a new primary diagnosis identified
during an inpatient stay?
Assign a separate code for the new diagnosis and ensure proper sequencing based on the
reason for admission and diagnosis priority
In coding for telehealth services, what documentation is required to ensure proper coding and
compliance?
Document the type of service, the provider’s location, the patient’s location, and the method
of communication (e.g., video or audio)
2
, A patient with chronic kidney disease (CKD) stage 3 is admitted with acute kidney injury (AKI).
How should these conditions be coded?
Code both CKD and AKI, with AKI listed as the primary condition if it is the reason for the
admission
For an outpatient claim, the coder identifies that a procedure code is no longer valid for the
current year. What is the coder's best action?
Review the latest coding updates, find the current replacement code, and use it to avoid
claim rejections
How should a coder proceed when a payer denies a claim based on medical necessity?
Review the documentation, confirm the accuracy of the diagnosis and procedure codes, and
resubmit with any additional supportive documentation if needed
A coder is assigning an ICD code for a patient with a primary complaint of chest pain. No further
diagnosis is determined during the visit. How should the coder document this?
Use the appropriate ICD code for “chest pain” as the final code, as no specific diagnosis was
made
3
Guide Exam Q&A| Latest Update 2025
During an outpatient clinic visit, the physician documents a primary diagnosis of diabetes with
complications involving retinopathy. Which code should the medical coder assign to capture both
the primary condition and its specific complication?
Diabetes with retinopathy code (assign based on specific ICD code set for diabetic
complications)
A coder receives a report where a procedure was performed on both knees for a patient with
bilateral knee osteoarthritis. How should the coder indicate that both knees were treated?
Use modifiers (e.g., modifier -50 for bilateral procedures) or assign separate procedure codes
for each knee, depending on payer guidelines
If a coder is assigning codes for a patient with suspected pneumonia but no confirmed diagnosis
was provided by the end of the visit, how should they code the condition?
Code based on the patient’s symptoms and clinical findings, as confirmed diagnoses are
required for coding
1
,A patient undergoes a surgery where multiple procedures are performed in one operative session.
How should a coder approach sequencing these codes?
List the most complex or primary procedure first, followed by additional codes for secondary
procedures, using any necessary modifiers
The physician notes a complication due to a previously implanted medical device. What coding
step should the coder take to reflect this complication?
Use the appropriate ICD code for complications of the device, referencing specific code
categories for implanted device issues
How should a coder document a scenario where a patient had a new primary diagnosis identified
during an inpatient stay?
Assign a separate code for the new diagnosis and ensure proper sequencing based on the
reason for admission and diagnosis priority
In coding for telehealth services, what documentation is required to ensure proper coding and
compliance?
Document the type of service, the provider’s location, the patient’s location, and the method
of communication (e.g., video or audio)
2
, A patient with chronic kidney disease (CKD) stage 3 is admitted with acute kidney injury (AKI).
How should these conditions be coded?
Code both CKD and AKI, with AKI listed as the primary condition if it is the reason for the
admission
For an outpatient claim, the coder identifies that a procedure code is no longer valid for the
current year. What is the coder's best action?
Review the latest coding updates, find the current replacement code, and use it to avoid
claim rejections
How should a coder proceed when a payer denies a claim based on medical necessity?
Review the documentation, confirm the accuracy of the diagnosis and procedure codes, and
resubmit with any additional supportive documentation if needed
A coder is assigning an ICD code for a patient with a primary complaint of chest pain. No further
diagnosis is determined during the visit. How should the coder document this?
Use the appropriate ICD code for “chest pain” as the final code, as no specific diagnosis was
made
3
