Question 1

If the pre- and postoperative diagnoses are different, the preoperative diagnosis should be reported.

Accepted Answer

The postoperative diagnosis is what should be reported because it is based on the findings during the surgery, making it more accurate and relevant for coding and billing purposes.

Question 2

Code all the documented conditions that coexist at the time of an encounter/visit and require or affect patient care, treatment, or management.

Accepted Answer

This is a requirement for accurate and complete medical coding in accordance with ICD-10-CM guidelines.

Question 3

Corneal ulcer with hypopyon of left eye.
ICD-10-CM Code: ___________________

Accepted Answer

H16.032

Question 4

Z codes cannot be used in the outpatient setting.

Accepted Answer

Z codes can be used in the outpatient setting for reasons such as preventive care, counseling, and follow-up visits. They are used to indicate a patient's health status or reasons for the encounter, and can assist with tracking health statistics and identifying trends in healthcare.

Question 5

A patient is admitted to an observation unit for a medical condition that has worsened and is then admitted as an inpatient to the same hospital for the same medical condition.The primary diagnosis would be the medical condition that led to the admission.

Accepted Answer

The primary diagnosis for the inpatient admission would be the same medical condition that led to the initial observation unit admission.

Question 6

An established patient is seen for management of diabetes and hypothyroidism and the physician spends equal time on each diagnosis.Identify the primary diagnosis(es).____________________

Accepted Answer

Both diabetes and hypothyroidism are the primary diagnoses as the physician spent equal time managing both conditions.

Question 7

Long-term (current) use of aspirin.
ICD-10-CM Code: ___________________

Accepted Answer

The answer of Long-term (current) use of aspirin.
ICD-10-CM Code: ___________________...

Question 8

In the outpatient setting, a diagnosis that is documented as "rule out" should not be reported.

Accepted Answer

"Rule out" is not a definitive diagnosis and should not be reported in the outpatient setting. It may be used to guide further diagnostic testing and evaluation, but should not be included as a final diagnosis code.

Question 9

Assign Z01.89, Encounter for other specified special examinations, for encounters for routine laboratory/radiology testing in the absence of any signs, symptoms, or associated diagnoses.

Accepted Answer

Z01.89 is the correct code for encounters for routine laboratory/radiology testing in the absence of any signs, symptoms, or associated diagnoses, as it specifies "other specified special examinations."

Question 10

Section IV of the Official Guidelines for Coding and Reporting applies to both the inpatient and outpatient settings.

Accepted Answer

Section IV of the Official Guidelines for Coding and Reporting specifically applies to outpatient coding and reporting, whereas other sections are designated for inpatient settings.

Question 11

Long-term (current) use of systemic steroids.
ICD-10-CM Code: ___________________

Accepted Answer

The answer of Long-term (current) use of systemic steroids.
ICD-10-CM Code:...

Question 12

An established patient is seen for migraines and seizures, to rule out the possibility of a brain tumor.Identify the primary diagnosis(es).____________________

Accepted Answer

Both migraines and seizures are potential symptoms of a brain tumor, and the purpose of the visit is to rule out that possibility. Therefore, both conditions are considered primary diagnoses for this encounter.

Question 13

The term "primary diagnosis" is the same as the first-listed diagnosis.

Accepted Answer

Primary diagnosis and first-listed diagnosis refer to the same thing, which is the condition or illness that is considered the primary reason for the patient seeking medical care. This diagnosis is typically listed first on the patient's medical records and is used for billing and coding purposes.

Question 14

For an outpatient service, a history code (Z80-Z87) may be assigned as a secondary code if the historical condition or family history has an impact on the current care or has an influence on the treatment.

Accepted Answer

A history code can be assigned as a secondary code if it has an impact on the current care or treatment.

Question 15

Z codes may be assigned as first-listed or a secondary diagnosis.

Accepted Answer

Z codes can be assigned as first-listed or secondary diagnosis depending on the reason for the encounter.

Question 16

A patient may have an unconfirmed diagnosis for more than three visits if a definitive diagnosis has not been stated by the physician in the medical documentation.

Accepted Answer

According to ICD-10-CM coding guidelines, a patient may have an unconfirmed diagnosis for more than three visits if a definitive diagnosis has not been stated by the physician in the medical documentation.

Question 17

In the inpatient hospital setting, probable, suspected, and rule-out diagnoses cannot be reported by the facility as though the condition exists.

Accepted Answer

In the inpatient hospital setting, probable, suspected, and rule-out diagnoses can be reported and coded as though the condition exists. This is because the coding guidelines allow for the use of these terms when a definitive diagnosis has not been established but the clinical evidence suggests a particular condition.

Question 18

Preoperative examination for a patient who will receive a renal transplant due to ESRD, currently on dialysis.
ICD-10-CM Codes: ____________________

Accepted Answer

The answer of Preoperative examination for a patient who will...

Question 19

When an encounter is for a therapeutic service, the first-listed code is the diagnosis, condition, or problem shown to be chiefly responsible for the therapeutic service.

Accepted Answer

According to the ICD-10-CM guidelines, when an encounter is for a therapeutic service, the first-listed code is the diagnosis, condition, or problem shown to be chiefly responsible for the therapeutic service.

Question 20

Screening for respiratory tuberculosis.
ICD-10-CM Code: ___________________

Accepted Answer

The answer of Screening for respiratory tuberculosis.
ICD-10-CM Code: ___________________...

Quiz 3: ICD-10-CM Outpatient Coding and Reporting Guidelines

If the pre- and postoperative diagnoses are different, the preoperative diagnosis should be reported.

Code all the documented conditions that coexist at the time of an encounter/visit and require or affect patient care, treatment, or management.

Corneal ulcer with hypopyon of left eye. ICD-10-CM Code: ___________________

Z codes cannot be used in the outpatient setting.

A patient is admitted to an observation unit for a medical condition that has worsened and is then admitted as an inpatient to the same hospital for the same medical condition.The primary diagnosis would be the medical condition that led to the admission.

An established patient is seen for management of diabetes and hypothyroidism and the physician spends equal time on each diagnosis.Identify the primary diagnosis(es) .____________________

Long-term (current) use of aspirin. ICD-10-CM Code: ___________________

In the outpatient setting, a diagnosis that is documented as "rule out" should not be reported.

Assign Z01.89, Encounter for other specified special examinations, for encounters for routine laboratory/radiology testing in the absence of any signs, symptoms, or associated diagnoses.

Section IV of the Official Guidelines for Coding and Reporting applies to both the inpatient and outpatient settings.

Long-term (current) use of systemic steroids. ICD-10-CM Code: ___________________

An established patient is seen for migraines and seizures, to rule out the possibility of a brain tumor.Identify the primary diagnosis(es) .____________________