CCS test 2 Questions With Complete
Solutions
A 34-year old woman at 24 weeks' gestation was
seen in follow-up due to findings of glycosuria. Her
fasting venous plasma glucose is 143 mg/dL. Given
this finding, the diagnosis of gestational diabetes
mellitus is established. Family history reveals that
both parents have diabetes mellitus. The patient
was started on both dietary and insulin therapy.
Final diagnoses and procedure: (1) Gestational
diabetes mellitus, (2) pregnancy, (3) insulin
maintenance, (4) family history of diabetes
mellitus. Correct Answers O24.414, Z83.3, Z3A.24
Comments: (1) Codes for gestational diabetes are
in subcategory O24.4. Only the code for insulin-
controlled diabetes is required when the patient is
treated with both diet and insulin.
A 47-year-old man was seen in the emergency
room with complaints of nausea, vomiting,
diarrhea, and cramping. The patient is a known
diabetic whose diabetes is secondary to history of
blunt trauma to the pancreas. Blood sugar levels
on admission were greater than 600 mg/dL.
Final diagnoses: (1) Secondary diabetic
ketoacidosis, (2) diabetes mellitus secondary to
history of blunt trauma to the pancreas. Correct
Answers E13.10, S36.209S
,Comments: (1) Codes from category E10-E11 are
not assigned for secondary diabetes. Secondary
diabetes is coded with category E13. (2) The
seventh character "S" is assigned to code S36.209
for the injury to the pancreas that precipitated the
diabetes mellitus, the sequela.
A 47-year-old obese man was admitted with chest
pain and difficulty swallowing, resulting in
regurgitation. The patient has a history of coronary
artery disease (CAD), but tests ruled out angina.
Based on negative test results and the patient's
history, it was established that the chest pain was
probably related to a heavy meal.
Final diagnoses: (1) Probable gastroesophageal
reflux disease (GERD), (2) CAD, (3) obesity.
Assign the appropriate codes. Correct Answers
K21.9 (GERD w/out esophagitis)
I25.10 (CAD)
E66.9 (obesity)
Comments: (1) Code K21.9 is assigned as the
principal diagnosis. In the inpatient setting, when a
diagnosis is documented as "probable,"
"suspected," "likely," "questionable," "possible," or
"still to be ruled out," or other similar terminology
of uncertainty, the condition is coded as though it
, were an established diagnosis. (2) Codes for chest
pain and difficulty swallowing are not reported
because they are related to the definitive
underlying condition.
Reference: ICD-10-CM and ICD-10-PCS Coding
Handbook, 2019 Revised Edition, pp. 57-58, 140-
141.
A 53-year-old male patient status post coronary
artery bypass graft (CABG) was readmitted to the
hospital after he developed redness and purulent
drainage from the deep sternal wires. The patient
quickly deteriorated after admission, became
septic, and went into shock two days after
admission. With aggressive intravenous antibiotic
management, the patient improved and was later
discharged.
The physician also documented Methicillin-resistant
Staphylococcus aureus sepsis and postoperative
septic shock.
How should this case be coded? Correct Answers
T81.42x, Infection following a procedure, deep
incisional surgical site, initial encounter
A41.02, Sepsis due to Methicillin resistant
Staphylococcus aureus
R65.21, Severe sepsis with septic shock
Solutions
A 34-year old woman at 24 weeks' gestation was
seen in follow-up due to findings of glycosuria. Her
fasting venous plasma glucose is 143 mg/dL. Given
this finding, the diagnosis of gestational diabetes
mellitus is established. Family history reveals that
both parents have diabetes mellitus. The patient
was started on both dietary and insulin therapy.
Final diagnoses and procedure: (1) Gestational
diabetes mellitus, (2) pregnancy, (3) insulin
maintenance, (4) family history of diabetes
mellitus. Correct Answers O24.414, Z83.3, Z3A.24
Comments: (1) Codes for gestational diabetes are
in subcategory O24.4. Only the code for insulin-
controlled diabetes is required when the patient is
treated with both diet and insulin.
A 47-year-old man was seen in the emergency
room with complaints of nausea, vomiting,
diarrhea, and cramping. The patient is a known
diabetic whose diabetes is secondary to history of
blunt trauma to the pancreas. Blood sugar levels
on admission were greater than 600 mg/dL.
Final diagnoses: (1) Secondary diabetic
ketoacidosis, (2) diabetes mellitus secondary to
history of blunt trauma to the pancreas. Correct
Answers E13.10, S36.209S
,Comments: (1) Codes from category E10-E11 are
not assigned for secondary diabetes. Secondary
diabetes is coded with category E13. (2) The
seventh character "S" is assigned to code S36.209
for the injury to the pancreas that precipitated the
diabetes mellitus, the sequela.
A 47-year-old obese man was admitted with chest
pain and difficulty swallowing, resulting in
regurgitation. The patient has a history of coronary
artery disease (CAD), but tests ruled out angina.
Based on negative test results and the patient's
history, it was established that the chest pain was
probably related to a heavy meal.
Final diagnoses: (1) Probable gastroesophageal
reflux disease (GERD), (2) CAD, (3) obesity.
Assign the appropriate codes. Correct Answers
K21.9 (GERD w/out esophagitis)
I25.10 (CAD)
E66.9 (obesity)
Comments: (1) Code K21.9 is assigned as the
principal diagnosis. In the inpatient setting, when a
diagnosis is documented as "probable,"
"suspected," "likely," "questionable," "possible," or
"still to be ruled out," or other similar terminology
of uncertainty, the condition is coded as though it
, were an established diagnosis. (2) Codes for chest
pain and difficulty swallowing are not reported
because they are related to the definitive
underlying condition.
Reference: ICD-10-CM and ICD-10-PCS Coding
Handbook, 2019 Revised Edition, pp. 57-58, 140-
141.
A 53-year-old male patient status post coronary
artery bypass graft (CABG) was readmitted to the
hospital after he developed redness and purulent
drainage from the deep sternal wires. The patient
quickly deteriorated after admission, became
septic, and went into shock two days after
admission. With aggressive intravenous antibiotic
management, the patient improved and was later
discharged.
The physician also documented Methicillin-resistant
Staphylococcus aureus sepsis and postoperative
septic shock.
How should this case be coded? Correct Answers
T81.42x, Infection following a procedure, deep
incisional surgical site, initial encounter
A41.02, Sepsis due to Methicillin resistant
Staphylococcus aureus
R65.21, Severe sepsis with septic shock
