CH4 ICD-10-CM

Question 1

What is the ICD-10-CM code for DM?

Answer 1

E11.9

Response Feedback:
DM is the medical abbreviation for diabetes mellitus. In the ICD-10-CM Alphabetic Index, look for Diabetes, diabetic (mellitus) (sugar). You are referred to E11.9. In the Tabular List locate code E11.9. ICD-10-CM Official Guideline Section I.C.4.a.2. states if the type of diabetes mellitus is not documented in the medical record the default is subcategory E11, type 2 diabetes mellitus.

Question 2

The patient is being treated for acute-on-chronic pansinusitis. What ICD-10-CM code(s) is/are reported?

Answer 2

J01.40, J32.4

Response Feedback:
According to ICD-10-CM guideline I.B.8 indicates when the same condition is described as both acute (subacute) and chronic, and there is not a combination code, code both and sequence the acute (subacute) code first. From the ICD-10-CM Alphabetic Index look for Pansinusitis/acute. This index refers you to J01.40. Look for Pansinusitis (chronic) (hyperplastic) (nonpurulent) (purulent). This index refers you to J32.4. Verify both codes in the Tabular List.

Question 3

When a patient is admitted for chemotherapy for cancer what code is reported as the first listed diagnosis?

Answer 3

Z51.11

Response Feedback:
ICD-10-CM guideline I.C.2.e.2 states if a patient admission/encounter is solely for the administration of chemotherapy, assign code Z51.11 as the first-listed or principal diagnosis. From the Index, reference Chemotherapy (session) (for)/cancer Z51.11. Verify the code in the Tabular List.

Question 4

Patient is admitted with SOB (shortness of breath) and cough with production of sputum. He has a history of COPD (chronic obstructive pulmonary disease) and is taking Symbicort. Diagnosis: Exacerbation of COPD. What ICD-10-CM code is reported?

Answer 4

J44.1

Response Feedback:
Rationale: In the ICD-10-CM Alphabetic Index look for Disease, diseased/pulmonary/chronic obstructive/with/exacerbation (acute) which leads to J44.1. Verify in the Tabular List. An exacerbation is different from an infection.

Question 5

The patient just turned 50 and is here today for a screening colonoscopy. During the procedure, two polyps are found and removed with a snare technique. What ICD-10-CM code(s) is/are reported?

Answer 5

Z12.11, K63.5

Response Feedback:
ICD-10-CM Guidelines, Section I.C.21.c.5 indicates, “A screening code may be a first listed code if the reason for the visit is specifically the screening exam…Should a condition be discovered during the screening, then the code for the condition may be assigned as an additional diagnosis.” The screening code is reported first. From the ICD-10-CM Alphabetic Index look for Screening/colonoscopy. This index refers you to Z12.11. Then look for Polyp, polypus/colon. This index refers you to K63.5. Verify both codes in the Tabular List.

Question 6

Patient is in the observation room with an impending CVA. The test results come back with the patient having a CVA and is admitted to the hospital. What ICD-10-CM code is reported?

Answer 6

I63.9

Response Feedback:
ICD-10-CM coding guideline I.B.11 indicates because the CVA did occur and is no longer impending, code the confirmed diagnosis. You will only report one code, the confirmed diagnosis CVA. CVA stands for Cerebrovascular accident. From the ICD-10-CM Alphabetic Index look for Accident/cerebrovascular (embolic) (ischemic) (thrombotic). This index refers you to I63.9 in the Tabular List.

Question 7

Patient presents with sore throat and fever. After an appropriate history and exam, and a positive strep test, the physician diagnosis is strep throat. What diagnosis code(s) is/are reported?

Answer 7

J02.0

In the ICD-10-CM Alphabetic Index, look for Sore/throat (acute) which is further indented to include the infectious organism, streptococcus (ulcerative). J02.0 is used as it includes the organism and the sore throat. Signs and symptoms are not coded when a final diagnosis is issued, therefore it is unnecessary to code for the fever also. Verify the code in the Tabular List.

Question 8

A 32-year-old has been admitted to a 45-day program for rehabilitation. She has a daily barbiturate dependence with anxiety disorder. What ICD-10-CM code(s) is/are reported?

Answer 8

F13.280

Response Feedback:
The key word is dependence. There is documentation that she has a drug dependence to the barbiturates. In the Alphabetic Index look for Dependence/barbiturates(s) (compound) (drugs classifiable to T42) which refers you to see Dependence, drug, sedative. Look for Dependence/drug/sedative/with/anxiety disorder refers you to code F13.280. Verify the code in the Tabular List.

Question 9

Patient is diagnosed with right bundle branch block. What ICD-10-CM code is reported?

Answer 9

I45.10

Response Feedback:
In the ICD-10-CM Alphabetic Index, look for Block/bundle branch/right, which leads the user to I45.10. Verify code selection in the Tabular List.

Question 10

Patient has upper GI endoscopy performed for epigastric abdominal pain, occult blood in feces, and weight loss over the past 2 months to rule out an ulcer. What ICD-10-CM code(s) is/are reported?

Answer 10

R10.13, R19.5, R63.4

Response Feedback:
This example does not provide a definitive diagnosis, so signs and symptoms are reported. In the ICD-10-CM Alphabetic Index look for Pain/epigastric, epigastrium leading to R10.13. Look for Blood/occult in feces leads to R19.5. Look for Weight/loss (abnormal) (cause unknown) which leads to R63.4. Verify all codes in the Tabular List.

Question 11

Patient is diagnosed with kidney stones. What ICD-10-CM code is reported?

Answer 11

N20.0

Response Feedback:
In the ICD-10-CM Alphabetic Index look for Stone(s)/kidney which leads to N20.0, calculus of kidney. Verify in the Tabular List. In the Tabular List, the inclusion terms below N20.0 list Stone in kidney.

Question 12

What is the ICD-10-CM code for GERD?

Answer 12

K21.9

Response Feedback:
GERD is the medical abbreviation for Gastroesophageal Reflux Disease. Option 1: In the ICD-10-CM Alphabetic Index, look for GERD gastroesophageal reflux disease and you are referred to code K21.9. Option 2: In the Alphabetic Index, look for Reflux/gastroesophageal and you are referred to the same code, K21.9. In the Tabular List locate code K21.9 Gastro-esophageal reflux disease without esophagitis.

Question 13

The patient’s dense breast tissue made the screening mammogram unreadable, and she is here today for a breast ultrasound. Her mother and aunt both have a history of breast cancer. What ICD-10-CM codes are reported for breast ultrasound?

Answer 13

Z12.39, R92.2, Z80.3

Response Feedback:
Code the special screening as a reason for the encounter, along with a code to report the patient’s breast density, which provides medical necessity for a more extensive test. Dense breast tissue occurs in many premenopausal women and can interfere with reading a mammogram and may mask abnormalities in the image. From the ICD-10-CM Alphabetic Index look for Screening/neoplasm (malignant) (of)/breast refers you to Z12.39. Next look for Dense/breast, refers you to R92.2. Finally look for History/family(of)/malignant neoplasm (of)/breast, refers you to Z80.3. Verify all codes in the Tabular List.

Question 14

What is the ICD-10-CM code for essential HTN?

Answer 14

I10

Response Feedback:
HTN is the medical abbreviation for hypertension. In the ICD-10-CM Alphabetic Index, look for Hypertension, hypertensive (accelerated) (benign) (essential) (idiopathic) (malignant) (systemic). The code next to Hypertension is I10. In the Tabular List locate code I10 and verify that it is the correct code for essential hypertension.

Question 15

What is the ICD-10-CM code for a cough?

Answer 15

R05.9

Response Feedback:
In the ICD-10-CM Alphabetic Index, look for Cough (affected) (epidemic) (nervous). You are referred to R05.9. In the Tabular List locate and verify that R05.9 is the correct code for cough unspecified.

Question 16

A patient who is HIV positive has been showing purplish nodules on the skin on different areas of the body. He is diagnosed with having Kaposi’s sarcoma which is a manifestation of having AIDS. What ICD-10-CM code(s) is/are reported?

Answer 16

B20, C46.0

Response Feedback:
According to ICD-10-CM guidelines section I.C.1.a.2.d: Z21, Asymptomatic human immunodeficiency virus [HIV] infection, is to be applied when the patient without any documentation of symptoms is listed as being HIV positive, known HIV, HIV test positive, or similar terminology. Do not use this code if the term AIDS is used or if the patient is treated for any HIV-related illness or is described as having any condition(s) resulting from his/her HIV positive status; use B20 in these cases. In the question the patient is showing a condition Kaposi’s sarcoma resulting from his HIV positive status, in which now code B20 AIDS will now be assigned.
From the ICD-10-CM Alphabetic Index look for AIDS (related complex). You are referred to B20. There is a note in the Tabular List to use additional code(s) to identify all manifestations of HIV infection. Next, look for Kaposi’s/sarcoma/skin (multiple sites). You are referred to C46.0. The scenario documented that this type of cancer was found on the skin of the patient. Verify in the Tabular List.

Question 17

Patient presents with difficulty speaking, facial droop, and she is unable to close her left eye. She has no other complaints. She is diagnosed with Bell’s palsy. She is prescribed Corticosteroids. She will return in 3 days for follow-up. What ICD-10-CM code(s) is/are reported?

Answer 17

G51.0

Response Feedback:
In the ICD-10-CM Alphabetic Index look for Bells/palsy, paralysis which leads to G51.0. Verify code in the Tabular List. Newborn palsy is P11.3. Signs and symptoms of facial droop and difficulty speaking are inherent to Bell’s palsy and not separately reported.

Question 18

What is the ICD-10-CM code for back pain?

Answer 18

M54.9

Response Feedback:
In the ICD-10-CM Alphabetic Index, look for Pain(s)/back (postural). You are referred to M54.9. In the Tabular List locate and verify code M54.9 is the correct code for back pain.

Question 19

A patient returns to her doctor three days later with nausea and rash due to taking Celebrex, a non-steroidal anti-inflammatory drug (NSAID). The physician notes that this is a drug reaction to the Celebrex and changes the medication. What ICD-10-CM code(s) is/are reported?

Answer 19

R11.0, L27.0, T39.395A

Response Feedback:
ICD-10-CM Coding guidelines I.C.19.e.5.a indicates: When coding an adverse effect of a drug that has been correctly prescribed and properly administered, assign the appropriate code for the adverse effect of the drug (T36-T50). There is a code first note for the adverse effects, the nature of the adverse effect. For the scenario, the effects of the drug were nausea (R11.0) and a rash due to the drug (L27.0). Do not use the code for rash, L21, as there is a more definitive code which is rash due to the internal use of drugs. In the ICD-10-CM Alphabetic Index, looks for Nausea (without vomiting) R11.0 and Rash/drug (internal use) L27.0.
Next, report the T code. In the Table of Drugs and Chemicals look for Anti-inflammatory drug/nonsteroidal NEC/Adverse effect (column). You are referred to T39.395, which needs a 7th character A to indicate this is the initial encounter. Verify all codes in the Tabular List.

Question 20

Patient is seen for urinary symptoms that include nocturia, hesitancy, frequency, and a weak urinary stream. Exam reveals that the patient has an enlarged prostate. What ICD-10-CM code(s) is/are reported?

Answer 20

N40.1, R35.1, R39.11, R35.0, R39.12

Response Feedback:
In the ICD-10-CM Alphabetic Index look for Enlargement, enlarged/prostate/with lower urinary tract symptoms which leads to N40.1, Enlarged prostate with lower urinary tract symptoms. When verifying in the Tabular List, a note states to use an additional code for associated symptoms. The nocturia R35.1, hesitancy R39.11, frequency R35.0, and weak urinary stream R39.12 are listed as associated symptoms.

Question 21

A patient presents with symptoms of chest pain, nausea, and pain in the neck and arm. He is diagnosed with a STEMI (or ST Elevation) myocardial infarction of the anterior wall. What ICD-10-CM code(s) is/are reported?

Answer 21

I21.09

Response Feedback:
A STEMI is an ST Elevated Myocardial Infarction. In the ICD-10-CM Alphabetic Index look for Infarct, infarction/myocardium myocardial/ST Elevation (STEMI)/anterior (anteroapical) (anteroseptal) (Q wave) (wall), which leads to I21.09. Chest pain, nausea, and pain in the neck and arm are symptoms of the MI and not separately reported. Verify code in the Tabular List.

Question 22

28-year-old OB patient presents with cramping, bleeding, and passing of tissue. She is diagnosed with a spontaneous abortion. Which ICD-10-CM code is reported?

Answer 22

O03.9

Response Feedback:
In the ICD-10-CM Alphabetic Index, look for Abortion (complete) (spontaneous). Category O03 is used for spontaneous abortion, which includes cramping, bleeding, and passing of tissue. The 4th character 9 without complications is used. Missed abortion is characterized by retained products, without bleeding or passing of tissue. Verify the code O03.9 in the Tabular List.

Question 23

Child is brought in by her mother for a skin rash on her arms, legs, and midsection. Mother states the patient has been playing in a field across from the house. She is diagnosed with chigger bites. What ICD-10-CM code is reported (do not code the External Cause)?

Answer 23

B88.0

Response Feedback:
In the ICD-10-CM Alphabetic Index look for chiggers (infestation), which leads to B88.0, Other ascariasis. Verify code selection in the Tabular List. Ascariasis is defined as infestation with or disease caused by mites.

Question 24

Two-month-old sees her pediatrician for a well-child visit and vaccinations. During the well-child examination, the physician documents the patient has a diaper rash. The physician prescribes an ointment for the rash. What is/are correct ICD-10-CM code(s) to report for this encounter?

Answer 24

Z00.121, Z23, L22

Response Feedback:
According to ICD-10-CM guidelines section I.C.21.c.13: During a routine exam, should a diagnosis or condition be discovered, it is coded as an additional code. Also, if a diagnosis or condition is discovered during the examination, the code for ‘with abnormal findings’ is assigned. In this example, a diaper rash was discovered on examination; therefore, it is considered an abnormal finding. In the ICD-10-CM Alphabetic Index, look for Examination/child (over 28 days old) /with abnormal finding. You are referred to Z00.121. This code is reported first as it is the main reason for the visit. Look for Rash/diaper referring you to L22. ICD-10-CM guideline I.C.21.c.2 indicates to use code Z23 as a secondary code if the inoculation is given as a routine part of a preventive healthcare visit. In the Alphabetic Index look for Vaccination (prophylactic)/encounter for Z23. Verify all codes in the Tabular List.

Question 25

A 30-year-old female suffers from menstrual migraines. She is in the ED because the medication has not relieved the migraine. What ICD-10-CM code is reported?

Answer 25

G43.839

Response Feedback:
From the Alphabetic Index look for Migraine/menstrual. This index refers you to G43.829. In the Tabular List, there is a note under the category G43 that states “Note: the following terms are to be considered equivalent to intractable: pharmacoresistant (pharmacologically resistant), treatment resistant, refractory (medically) and poorly controlled.” Therefore, since the migraine is not responding to medication, it is considered intractable. Further reference in the Tabular List shows the correct code to be G43.839.

Question 26

A patient was seen for a left ear infection. The provider diagnosed the patient with Swimmer’s Ear in the left ear. The biller received a denial from XYZ Insurance Company stating H60.33 is an invalid diagnosis code. Why is this an invalid code?

Answer 26

H60.33 requires an additional character; the code should be H60.332

Response Feedback:
H60.33 is a subcategory code that requires an additional character to be complete. The ear affected is the left ear. Look in the ICD-10-CM Tabular List and find that H60.332 represents Swimmer’s ear in the left ear.

Question 27

A patient is seen for a cough, chest congestion, and a headache. The provider documents a URI. What ICD-10-CM coding is reported?

Answer 27

J06.9

Response Feedback:
Signs and symptoms are not reported when a definitive diagnosis is given (ICD-10-CM guideline I.B.4.). Look in the ICD-10-CM Alphabetic Index for Infection/respiratory (tract)/upper (acute) J06.9. Verify code selection in the Tabular List.

Question 28

What codes are reported for a patient that is being treated for ESRD and hypertension?

Answer 28

I12.0, N18.6

Response Feedback:
The ICD-10-CM guideline (I.C.9.a.2) indicates to assign codes for category I12 with code from category N18 as the relationship between hypertension and chronic kidney disease is presumed.

Question 29

A patient complains of a severe sore throat, a fever and headache. Based on the results of a rapid strep test the provider determines the patient has strep throat. What ICD-10-CM coding is reported?

Answer 29

J02.0

Response Feedback:
The ICD-10-CM guideline (I.B.18) states when a definitive diagnosis is documented by the provider, the signs and symptoms of the condition would not be reported separately. If the provider was waiting for the results of the lab work, the signs and symptoms would be reported.

Question 30

What should a biller do if the ICD-10-CM instructions indicate “ See” or “ See Also?”

Answer 30

Go to the main term referenced with the “see” note to locate the correct code

Response Feedback:
The “see” or “see also” indicates that another term should be referenced for correct code selection.

Question 31

Which ICD-10-CM must be listed first on a claim?

Answer 31

Z51.0

Response Feedback:
The ICD-10-CM guideline (I.C.21.c.16) indicates that Z51.0 must be reported as the principal/first-listed diagnosis, except when there are multiple encounters on the same day and the medical records for the encounters are combined.

Question 32

A patient presents with a lump in the lower inner quadrant of her right breast. The provider orders a mammogram. What is the correct ICD-10-CM code for the encounter?

Answer 32

N63.14

Response Feedback:
Without a confirmed diagnosis of a neoplasm, the office visit should be coded with the symptom that is being treated. Look in the ICD-10-CM Alphabetic Index for Lump/breast/right/lower inner quadrant. Verify in the Tabular List.

Question 33

A 3 year-old is seen for ear infections in both of his ears. The provider’s assessment indicates that the infection is worse in the child’s right ear. What ICD-10-CM code(s) should be assigned?

Answer 33

H66.93

Response Feedback:
The infection is found in both ears, so the appropriate code would indicate bilateral. The documentation of the infection being worse in one ear versus the other would not warrant the coding of both codes.

Question 34

A patient has a burn that the provider notates as non-healing. How should this be coded?

Answer 34

Code as an acute burn

Response Feedback:
The ICD-10-CM guideline (I.C.19.d.3) indicates to code, “non-healing burns as acute burns.”