Guidelines
True or False
“Signs and symptoms should be coded when a definitive diagnosis is documented.”
False (Section I.B.4)
True or False
Codes labeled “in diseases classified elsewhere” can be used as primary diagnoses.
False — they must never be primary (I.A.12)
When coding combination codes (like diabetes with neuropathy), you should:
A. Assign separate codes
B. Assign the combination code only
C. Assign both the combination code and separate codes
B (I.B.7)
“Excludes1” means:
A. Two conditions cannot ever be coded together
B. Conditions may be coded together
C. Either code may be used first
A (I.A.12.a)
Hypertension (HTN)
I10
Fever, unspecified
True or False
“With” in the Alphabetic Index means the conditions are automatically linked unless stated otherwise.
True (I.A.15)
True or False
A “history of” Z code is used when the condition is no longer active.
True (I.C.21)
If a condition is not yet confirmed, but is documented as “suspected, ruled out, or possible” for an outpatient visit, you should code:
A. As if confirmed
B. The signs/symptoms only
C. Nothing
B (IV.H)
For sepsis due to a specific organism, sequencing is:
A. Organism first
B. Sepsis code first
C. Z16 first
B (I.C.1.d)
Benign Prostatic Hyperplasia (BPH)
N40.0 (unspecified)
Generalized Anxiety Disorder (GAD)
F41.1
True or False
Late effects are coded as the cause first and the residual condition second.
False — residual/condition first, cause second (I.B.10)
True or False
For OB encounters, weeks of gestation should always be coded.
True (I.C.15.a.6)
Sequela guidelines tell us to code:
A. Cause first, sequela second
B. Sequela first, cause second
C. Both but order doesn’t matter
B (I.B.10)
What does “NOS” stand for in ICD-10-CM?
A. Not otherwise specified
B. Not on schedule C. New onset symptoms
D. Not officially standardized
A. Not otherwise specified
Type 2 Diabetes Mellitus without complications
E11.9
BMI 30-39.9 (Obesity, Class 1)
Z68.30
True or False
Z codes can be listed as a principal diagnosis.
True (depending on encounter reason)
True or False
Late effects (sequela) may occur months or years after an injury.
True (I.B.10)
When coding anemia due to malignancy, what is the correct sequencing?
A. Anemia first
B. Malignancy first
C. Either one
B (I.C.2.c.1)
When a provider documents “left knee pain,” which guideline applies?
A. Never code pain
B. Code only acute conditions
C. Use laterality when available
D. Use external cause codes
C. Use laterality when available
Acute Pharyngitis
J02.9
Otitis Media, unspecified
H66.90
True or False
Laterality should always be coded when available.
True (I.B.12)
True or False
If documentation lists “acute on chronic” and only one code exists, use the acute code.
False — use the combination code if provided (I.B.8)
External cause codes are:
A. Required in all cases
B. Optional unless payer requires
C. Required only for children
B (I.C.20)
The main term you choose in the ICD-10-CM index is determined by:
A. Anatomical site
B. The documented diagnosis
C. The physician’s specialty
B (Official conventions)
Acute Cystitis without hematuria
N30.00
Allergic Rhinitis, unspecified
J30.9