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Question 1 reset
A 65-year-old male with a history of COPD is admitted with increased shortness of breath, productive cough with yellow sputum, and fever. Chest X-ray reveals consolidation in the right lower lobe. The physician documents "pneumonia due to Streptococcus pneumoniae." What is the principal diagnosis?
Question 2 reset
A patient presents to the outpatient clinic for a follow-up after a laparoscopic cholecystectomy performed two weeks prior. The incision site is well-healed, and the patient reports feeling well. What ICD-10-CM code(s) should be assigned?
Question 3 reset
A patient is admitted with acute chest pain. Cardiac enzyme levels are elevated. The final diagnosis is ST-elevation myocardial infarction of the anterior wall. What ICD-10-CM code should be assigned?
Question 4 reset
A 30-year-old female presents to the emergency department after falling from a bicycle. X-rays reveal a closed fracture of the distal shaft of the right tibia. What ICD-10-CM code should be assigned?
Question 5 reset
A patient undergoes a colonoscopy, and a polyp is removed via snare technique. The pathology report reveals a tubular adenoma. What CPT code(s) should be assigned?
Question 6 reset
A patient with a history of hypertension is admitted for a stroke. The physician documents "acute ischemic stroke due to thrombosis of the left middle cerebral artery." What is the principal diagnosis?
Question 7 reset
A Medicare patient is seen in the outpatient clinic for physical therapy following a total knee arthroplasty performed 6 weeks ago. What ICD-10-CM code(s) should be reported?
Question 8 reset
During an inpatient encounter for pneumonia, the patient develops acute respiratory failure requiring intubation and mechanical ventilation. How should these conditions be coded and sequenced?
Question 9 reset
A patient presents to the emergency department with a laceration on their forearm. The physician repairs the 3.5 cm simple laceration with sutures. What CPT code should be reported?
Question 10 reset
A patient with diabetes mellitus develops a non-healing ulcer on their left foot. The physician documents "diabetic ulcer of left foot with infection." What ICD-10-CM codes should be assigned?
Question 11 reset
A coder notes that the physician documented "rule out myocardial infarction" in the progress notes on day one, but the discharge summary states "acute myocardial infarction." How should the coder proceed?
Question 12 reset
The physician's documentation states "status post laparoscopic appendectomy." Where in the health record should the coder look for details about the reason for the appendectomy?
Question 13 reset
A patient is admitted for pneumonia. On the third day of the hospital stay, the patient develops a urinary tract infection (UTI) that was not present on admission. How should the UTI be coded?
Question 14 reset
A physician performs a cystoscopy with fulguration of a bladder tumor in the outpatient setting. What CPT code(s) should be reported?
Question 15 reset
A patient is admitted with dehydration due to severe vomiting and diarrhea. The physician documents "acute gastroenteritis with dehydration." What is the principal diagnosis?
Question 16 reset
A coder is reviewing a record and notices that the physician has documented two different laterality for the same condition in different parts of the record. What should the coder do?
Question 17 reset
A patient is seen in the emergency department for a deep laceration of the left hand. The physician performs an intermediate repair of a 4 cm laceration. What CPT code should be reported?
Question 18 reset
A patient with chronic kidney disease (CKD) stage III is admitted for pneumonia. What ICD-10-CM codes should be assigned and in what order?
Question 19 reset
A physician performs a diagnostic colonoscopy. During the procedure, no abnormalities are found. What CPT code should be reported?
Question 20 reset
A patient is admitted for a laparoscopic cholecystectomy for symptomatic gallstones. The operative report confirms the presence of multiple gallstones and no complications. What ICD-10-CM code(s) should be assigned?
Question 21 reset
A coder is reviewing a physician query that asks, "Could the shortness of breath be related to the patient's known COPD?" Is this query compliant?
Question 22 reset
Which of the following is a key element of an ethically compliant physician query?
Question 23 reset
A patient is admitted with a fever of unknown origin. After several days of testing, the final diagnosis is determined to be infective endocarditis. How should the initial fever be coded?
Question 24 reset
A patient undergoes a laparoscopic appendectomy for acute appendicitis with perforation and localized peritonitis. What ICD-10-CM codes should be assigned?
Question 25 reset
A patient is seen in the outpatient clinic for removal of sutures following a minor surgical procedure performed at the same facility one week prior. What CPT code should be reported?
Question 26 reset
A patient is admitted with acute bronchitis. During the hospital stay, the patient develops pneumonia. What is the principal diagnosis?
Question 27 reset
A patient is seen in the emergency department for a foreign body in the nose. The physician removes the foreign body. What CPT code should be reported?
Question 28 reset
A patient with a history of congestive heart failure (CHF) is admitted with worsening shortness of breath and fluid retention. The physician documents "acute exacerbation of chronic congestive heart failure." What ICD-10-CM code should be assigned?
Question 29 reset
A patient undergoes a diagnostic upper gastrointestinal (GI) endoscopy with biopsy of the stomach. What CPT code(s) should be reported?
Question 30 reset
A patient is admitted for a total hip arthroplasty. The physician documents the procedure was performed due to severe osteoarthritis of the right hip. What ICD-10-CM codes should be assigned?
Question 31 reset
A coder is reviewing a record for an outpatient surgery and notices a discrepancy between the preoperative diagnosis and the postoperative diagnosis. What should the coder do?
Question 32 reset
A patient presents to the emergency department with chest pain. The physician orders cardiac enzymes, which are negative. The ECG shows no acute changes. The physician's final diagnosis is "atypical chest pain." What ICD-10-CM code should be assigned?
Question 33 reset
A patient undergoes a laparoscopic cholecystectomy. During the procedure, the surgeon also performs a lysis of adhesions in the abdominal cavity. How should this be coded?
Question 34 reset
A patient with well-controlled type 2 diabetes mellitus is admitted for a fractured ankle. What is the principal diagnosis?
Question 35 reset
A patient is seen in the outpatient clinic for a follow-up of a urinary tract infection (UTI) that was treated with antibiotics. The patient reports resolution of symptoms. What ICD-10-CM code should be assigned?
Question 36 reset
A patient is admitted with acute kidney injury (AKI) due to dehydration secondary to severe diarrhea. What is the principal diagnosis?
Question 37 reset
A physician performs a flexible sigmoidoscopy and removes two polyps via hot biopsy forceps. What CPT code(s) should be reported?
Question 38 reset
A patient with a history of atrial fibrillation on anticoagulants is admitted for a fall resulting in a fractured hip. What is the principal diagnosis?
Question 39 reset
A coder identifies a situation where the physician's documentation is unclear about whether a condition was present on admission. What should the POA indicator be?
Question 40 reset
A patient is seen in the emergency department for a superficial burn of the forearm. The physician documents the burn as first-degree and covering 5% of the body surface area. What ICD-10-CM code should be assigned?
Question 41 reset
A patient undergoes a coronary artery bypass graft (CABG) surgery. The operative report lists three grafts using autologous saphenous vein grafts. What CPT code should be reported?
Question 42 reset
A patient is admitted with pneumonia. The physician's progress notes mention "possible sepsis," but the discharge summary does not confirm sepsis. How should sepsis be coded?
Question 43 reset
A patient is seen in the outpatient clinic for a routine annual physical examination. What ICD-10-CM code should be assigned?
Question 44 reset
A patient is admitted for a laparoscopic inguinal hernia repair. The physician documents a direct inguinal hernia. What ICD-10-CM code should be assigned?
Question 45 reset
A coder is reviewing a record and needs to determine the appropriate DRG for an inpatient stay. What type of software would be used for this purpose?
Question 46 reset
A patient is seen in the emergency department for a dog bite of the left leg. The physician cleans and dresses the wound. What ICD-10-CM code(s) should be assigned?
Question 47 reset
A patient undergoes a diagnostic bronchoscopy with bronchoalveolar lavage. What CPT code should be reported?
Question 48 reset
A hospital implements a new Computer-Assisted Coding (CAC) system. What is a potential impact of CAC on the coding process?
Question 49 reset
A patient is admitted with community-acquired pneumonia. The physician documents that the patient was intubated and mechanically ventilated for three days due to respiratory distress. How should the mechanical ventilation be coded?
Question 50 reset
Which of the following is a key objective of the Uniform Hospital Discharge Data Set (UHDDS)?

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