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CCS-P Medical Coding study materials
CCS-P Medical Coding study resources

CCS-P Medical Coding practice questions

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Question 1Medical Coding (ICD-10-CM diagnosis coding)

Under ICD-10-CM conventions, what does an Excludes1 note beneath a code indicate?

  1. The excluded condition is reportable only on inpatient encounters
  2. The excluded condition may be reported separately in addition to the code above the note
  3. The excluded condition must be sequenced before the code above the note
  4. The excluded condition cannot be reported with the code above the note because the two cannot occur together Correct answer.

Explanation

An Excludes1 note is a pure exclusion: the excluded code is "not coded here" and may never be reported on the same record as the code above the note. It is used when the two conditions are mutually exclusive, such as a congenital form versus an acquired form of the same condition.

Question 2Medical Coding (ICD-10-CM diagnosis coding)

How should a coder interpret an Excludes2 note under a code?

  1. The excluded condition is not included in the code but may be reported separately if both conditions are present Correct answer.
  2. The code above the note may not be used for outpatient reporting
  3. The two conditions may never be reported together on the same record
  4. The excluded condition must be added as a manifestation code following the etiology code

Explanation

Excludes2 means "not included here" - the condition is distinct from the one described by the code and is reportable as an additional code when documented. It differs from Excludes1, which prohibits reporting both codes together.

Question 3Medical Coding (ICD-10-CM diagnosis coding)

A tabular list entry carries the instruction "Code first" in italics. What does this instruction mean?

  1. The underlying etiology or cause is sequenced first and is followed by the listed code Correct answer.
  2. The listed code may never be used as a principal diagnosis
  3. The listed code is reported only when no more specific code exists
  4. The listed code is sequenced first and is followed by the underlying cause

Explanation

"Code first" identifies a manifestation that must follow the underlying condition, so the etiology is sequenced ahead of the listed code. The two codes are still both reported; the note governs order only.

Question 4Medical Coding (ICD-10-CM diagnosis coding)

A patient is treated in the emergency department for the first time for a fractured left wrist and is placed in a cast. Which 7th character applies to the fracture code?

  1. A Correct answer.
  2. S
  3. D
  4. G

Explanation

The 7th character A is used for the initial encounter, meaning the patient is receiving active treatment for the fracture. Active treatment includes emergency department care, surgery, casting, and evaluation by a new provider.

Question 5Medical Coding (ICD-10-CM diagnosis coding)

When an injury is reported with an external cause code, where does the external cause code belong?

  1. As the principal diagnosis before the injury code
  2. As a secondary code after the injury code Correct answer.
  3. Only on inpatient claims, never on outpatient claims
  4. Nowhere, because it replaces the injury code when the injury is minor

Explanation

External cause codes describe how and where the injury occurred and are always reported as secondary codes following the injury code. They are never sequenced as the principal or first-listed diagnosis.

Question 6Medical Coding (ICD-10-CM diagnosis coding)

In ICD-10-CM obstetric coding, which range of gestational ages defines the second trimester?

  1. 1 week 0 days through 13 weeks 6 days
  2. 14 weeks 0 days through 27 weeks 6 days Correct answer.
  3. 20 weeks 0 days through 36 weeks 6 days
  4. 28 weeks 0 days through 40 weeks 6 days

Explanation

The first trimester ends at 13 weeks 6 days, the second trimester runs from 14 weeks 0 days through 27 weeks 6 days, and the third trimester begins at 28 weeks 0 days. Trimester is assigned from the provider's documentation of gestational age.

Question 7Medical Coding (ICD-10-CM diagnosis coding)

A patient complains of abdominal pain, and the provider documents "abdominal pain, cause undetermined." What should be coded?

  1. A screening code from category Z11
  2. The code for the most likely underlying disease process
  3. The symptom code for abdominal pain Correct answer.
  4. No code, because no definitive diagnosis was established

Explanation

When a definitive diagnosis has not been established, the coder reports the symptom or sign that prompted the encounter rather than an unconfirmed condition. Coding a disease that has not been diagnosed would misrepresent the record.

Question 8Medical Coding (ICD-10-CM diagnosis coding)

A patient with type 2 diabetes has injected insulin daily for three years. Which additional code documents the long-term insulin use?

  1. E11.9
  2. Z71.3
  3. Z79.4 Correct answer.
  4. Z91.14

Explanation

Category Z79 is used for long-term (current) drug therapy, and Z79.4 specifically identifies long-term use of insulin. It is reported as an additional code alongside the diabetes code, which remains the code for the disease itself.

Question 9Medical Coding (ICD-10-CM diagnosis coding)

A patient with type 2 diabetes is diagnosed with diabetic chronic kidney disease, stage 3a. Which codes are reported?

  1. E11.65 and N18.9
  2. E11.9 and N18.31
  3. E11.22 and N18.31 Correct answer.
  4. E11.22 only

Explanation

Diabetic chronic kidney disease is captured by the combination code E11.22, which requires an additional code to identify the stage of chronic kidney disease. Stage 3a is reported with N18.31.

Question 10Medical Coding (ICD-10-CM diagnosis coding)

A patient with long-standing hypertension is diagnosed with hypertensive heart disease and heart failure. Which codes should be reported?

  1. I50.9 only
  2. I11.9 only
  3. I10 and I50.9
  4. I11.0 and I50.9 Correct answer.

Explanation

Hypertensive heart disease with heart failure is reported with the combination code I11.0, with an additional code identifying the type of heart failure. Reporting I10 with a heart failure code would fail to capture the causal relationship documented by the provider.

Question 11Medical Coding (ICD-10-CM diagnosis coding)

A patient with chronic obstructive pulmonary disease is seen for an acute exacerbation. Which code is assigned?

  1. J43.9
  2. J20.9
  3. J44.1 Correct answer.
  4. J44.9

Explanation

J44.1 is the specific code for chronic obstructive pulmonary disease with acute exacerbation. When the provider documents an exacerbation, the more specific code is required rather than the unspecified COPD code.

Question 12Medical Coding (ICD-10-CM diagnosis coding)

A patient is admitted with sepsis due to an unspecified organism and is documented as having severe sepsis without septic shock. Which codes are reported?

  1. A41.9 and R65.20 Correct answer.
  2. A41.9 and R65.21
  3. A41.9 only
  4. R65.20 only

Explanation

The underlying systemic infection is coded first with A41.9, followed by the code for severe sepsis, R65.20. R65.20 is never reported as the principal diagnosis because it requires an underlying infection code.

Question 13Medical Coding (ICD-10-CM diagnosis coding)

A patient with stage 4 chronic kidney disease is diagnosed with anemia in chronic kidney disease. Which statement describes the correct coding?

  1. D63.1 is sequenced first, followed by N18.4
  2. D64.9 is reported with N18.4 because the anemia type is not specified
  3. D63.1 is reported alone because it includes the CKD stage
  4. N18.4 is sequenced first, followed by D63.1 Correct answer.

Explanation

D63.1 carries a code-first instruction for the underlying chronic kidney disease, so N18.4 is sequenced first and D63.1 follows. The anemia code must not be reported alone, because the etiology is known and documented.

Question 14Medical Coding (ICD-10-CM diagnosis coding)

A patient is treated for a stage 3 pressure ulcer of the sacrum. Which code is assigned?

  1. L89.152
  2. L89.154
  3. L89.153 Correct answer.
  4. L89.156

Explanation

Category L89 codes pressure ulcers by site and stage, with the sacral region reported under L89.15- and the final character indicating stage. Stage 3 corresponds to the final character 3, giving L89.153.

Question 15Medical Coding (ICD-10-CM diagnosis coding)

Eight weeks after an ankle fracture, a patient returns for follow-up and the provider documents that the fracture is healing normally. Which 7th character is assigned?

  1. D Correct answer.
  2. S
  3. G
  4. A

Explanation

The 7th character D is used for a subsequent encounter for a fracture with routine healing. Character A would apply only while the patient is still receiving active treatment for the injury.

Question 16Medical Coding (ICD-10-CM diagnosis coding)

A patient who took penicillin exactly as prescribed develops urticaria. How is this reported?

  1. Underdosing of penicillin with urticaria
  2. Only the symptom code for urticaria
  3. Adverse effect of penicillin with the nature of the adverse effect Correct answer.
  4. Poisoning by penicillin with urticaria

Explanation

A reaction to a drug that was correctly prescribed and properly administered is an adverse effect, reported with the therapeutic drug code plus a code for the nature of the reaction. Poisoning requires incorrect use, such as an overdose or wrong substance given in error.

Question 17Medical Coding (ICD-10-CM diagnosis coding)

A patient misunderstood the instructions and took half the prescribed dose of an anticonvulsant, then presented with increased seizure activity. Which code describes the medication issue?

  1. Poisoning by the anticonvulsant
  2. Underdosing of the anticonvulsant Correct answer.
  3. Adverse effect of the anticonvulsant
  4. Noncompliance with the medication regimen

Explanation

Taking less of a medication than prescribed is reported with an underdosing code from the T36-T50 range, along with a code for the resulting condition and an external cause code. Adverse effect and poisoning codes apply to reactions to or incorrect administration of the drug, not to a subtherapeutic dose.

Question 18Medical Coding (ICD-10-CM diagnosis coding)

A patient at 20 weeks' gestation with an uncomplicated pregnancy is seen for a routine prenatal visit. Which code is assigned?

  1. Z34.92 Correct answer.
  2. Z34.90
  3. Z33.1
  4. O26.899

Explanation

Supervision of a normal pregnancy is reported with category Z34, with a final character identifying the trimester. At 20 weeks the patient is in the second trimester, so Z34.92 is assigned.

Question 19Medical Coding (ICD-10-CM diagnosis coding)

A patient with a known, untreated primary breast cancer is found to have metastasis to the bone. Which coding is correct?

  1. C50.919 only, because the primary site is always reported alone
  2. C79.51 only, because it describes the current problem
  3. C50.919 and C79.51, with the primary malignancy sequenced first Correct answer.
  4. C79.51 and C50.919, with the secondary malignancy sequenced first

Explanation

When a primary malignancy is still present and has not been excised or eradicated, both the primary site and the secondary site are coded, with the primary malignancy sequenced first. Each secondary site is reported with its own code from category C79.

Question 20Medical Coding (ICD-10-CM diagnosis coding)

A provider documents obesity and a body mass index of 37.2 for an adult patient. How are these reported?

  1. E66.9 and Z68.37 Correct answer.
  2. E66.9 only, because BMI is included in the obesity code
  3. Z68.37 only, because the BMI is the more specific code
  4. E66.01 and Z68.37

Explanation

Obesity is coded from category E66 as documented; the provider documented obesity without further specification, so E66.9 is assigned. BMI codes from category Z68 are reported as additional codes when the specific BMI is documented, and Z68.37 covers a BMI of 37.0 to 37.9 in an adult.

Question 21Medical Coding (ICD-10-CM diagnosis coding)

A patient with chronic systolic heart failure is admitted with worsening symptoms, and the provider documents acute on chronic systolic heart failure. Which code is assigned?

  1. I50.23 Correct answer.
  2. I50.43
  3. I50.22
  4. I50.33

Explanation

Category I50 distinguishes acute, chronic, and acute on chronic heart failure as well as the type. Acute on chronic systolic heart failure is reported with I50.23.

Question 22Medical Coding (ICD-10-CM diagnosis coding)

A patient with type 2 diabetes is documented as having a diabetic foot ulcer. Which coding approach is correct?

  1. E11.621 only
  2. E11.9 plus an additional code identifying the site of the ulcer
  3. A code for the ulcer site only
  4. E11.621 plus an additional code identifying the site of the ulcer Correct answer.

Explanation

Diabetic foot ulcer is captured by the combination code E11.621, which carries an instruction to add a code identifying the site of the ulcer. Reporting the ulcer site alone would lose the diabetic etiology documented by the provider.

Question 23Medical Coding (ICD-10-CM diagnosis coding)

A patient is evaluated for a residual gait abnormality six months after a femur fracture that has completely healed. How is this reported?

  1. The fracture code with 7th character A plus a gait abnormality code
  2. The fracture code with 7th character D only
  3. The gait abnormality code only
  4. A sequela code with 7th character S sequenced first, followed by the gait abnormality code Correct answer.

Explanation

A residual condition following the healed phase of an injury is a sequela and is reported with the injury code carrying 7th character S, sequenced before the code for the residual effect. The acute fracture code is no longer appropriate because the fracture has healed.

Question 24Medical Coding (ICD-10-CM diagnosis coding)

A patient completed treatment for colon cancer two years ago and now has no evidence of disease. Today's visit is for a routine checkup. Which code identifies the cancer history?

  1. C18.9
  2. Z86.010
  3. Z08
  4. Z85.038 Correct answer.

Explanation

Category Z85 is used when a primary malignancy has been previously treated and no longer exists, and Z85.038 identifies a personal history of other malignant neoplasm of the large intestine. A current malignancy code is reserved for disease that is still being treated or present.

Question 25Medical Coding (ICD-10-CM diagnosis coding)

A patient with breast cancer is admitted solely to receive an intravenous chemotherapy session. What is the principal diagnosis?

  1. T45.1X5A
  2. Z51.81
  3. C50.919
  4. Z51.11 Correct answer.

Explanation

When the admission is solely for the administration of chemotherapy, Z51.11 is assigned as the principal diagnosis, with the malignancy reported as an additional code. The encounter is for the therapy itself, not for treatment of a complication or of the tumor directly.

Question 26Medical Coding (ICD-10-CM diagnosis coding)

A code in the Tabular List carries an Excludes1 note naming another code. What does this note indicate?

  1. The two conditions cannot occur together, so the codes are not reported together. Correct answer.
  2. The excluded code must be sequenced before the code carrying the note.
  3. The two conditions may be coded together when both are documented.
  4. The listed conditions are always reported as additional diagnoses.

Explanation

An Excludes1 note means the excluded code and the code carrying the note are mutually exclusive, because the two conditions cannot occur together. Excludes2 notes permit reporting both codes when both conditions are present.

Question 27Medical Coding (ICD-10-CM diagnosis coding)

An ICD-10-CM code requires a seventh character, but the sixth character position does not apply to the diagnosis. What is entered in the sixth position?

  1. The numeral 0
  2. The letter X Correct answer.
  3. Nothing; a six-character code is reported
  4. A hyphen

Explanation

The placeholder character X is used to fill a character position when a code requires a seventh character but the sixth character is not applicable. This preserves the required character length of the code.

Question 28Medical Coding (ICD-10-CM diagnosis coding)

In an injury code that requires a seventh character, what does the character A represent?

  1. Subsequent encounter with delayed healing
  2. Subsequent encounter with routine healing
  3. Initial encounter Correct answer.
  4. Sequela of the injury

Explanation

The seventh character A denotes the initial encounter, meaning the patient is receiving active treatment for the condition. Subsequent encounters are reported with D, and sequelae with S.

Question 29Medical Coding (ICD-10-CM diagnosis coding)

An asymptomatic adult with no family history of colorectal disease comes in for a screening colonoscopy. Which code is assigned?

  1. Z12.11 screening for malignant neoplasm of colon Correct answer.
  2. Z13.9 screening, unspecified
  3. Z00.00 general adult medical examination
  4. Z80.0 family history of malignant neoplasm of digestive organs

Explanation

A screening colonoscopy in a patient without symptoms is reported with the specific screening code for the neoplasm being screened for, which is Z12.11. The screening code is first-listed when the encounter is solely for screening.

Question 30Medical Coding (ICD-10-CM diagnosis coding)

A patient with atrial fibrillation has taken warfarin daily for two years and is seen today for an unrelated complaint. Which code documents the long-term medication use?

  1. D68.9, coagulopathy, unspecified
  2. Z79.01, long-term (current) use of anticoagulants Correct answer.
  3. Z79.899, other long-term (current) drug therapy
  4. Z91.14, patient's other noncompliance with medication regimen

Explanation

Z79.01 specifically identifies long-term current use of anticoagulants and is reported as an additional code when the medication is taken for a chronic condition. The residual category Z79.899 is used only when no specific drug-therapy code exists.

Question 31Medical Coding (ICD-10-CM diagnosis coding)

A provider documents osteoarthritis of the knee but does not identify which knee is affected. How should the diagnosis be coded?

  1. Hold the claim until the side is documented
  2. Assign the right knee code by convention
  3. Assign both the left and right knee codes
  4. Assign the code for an unspecified knee Correct answer.

Explanation

ICD-10-CM provides right, left, and unspecified laterality options, and the unspecified side code is used when the medical record does not document laterality. A query to the provider is encouraged, but the record as documented must be coded.

Question 32Medical Coding (ICD-10-CM diagnosis coding)

A code carries a Code first note naming another condition. What does the instruction require?

  1. The named condition is reported only when it is the reason for the visit.
  2. The code carrying the note is sequenced first.
  3. The two conditions are combined into a single code.
  4. The named condition is sequenced before the code carrying the note. Correct answer.

Explanation

A Code first note instructs the coder to sequence the underlying or causal condition before the code carrying the note. The note appears under conditions that are manifestations of another disease.

Question 33Medical Coding (ICD-10-CM diagnosis coding)

An adult with no current complaints is seen for a general medical examination, and no abnormal findings are documented. Which code is assigned?

  1. Z13.9
  2. Z01.419
  3. Z00.01
  4. Z00.00 Correct answer.

Explanation

Z00.00 reports an encounter for a general adult medical examination without abnormal findings. If the examiner documents abnormal findings, Z00.01 is used together with the codes for those findings.

Question 34Medical Coding (ICD-10-CM diagnosis coding)

A patient with hypertension is documented as having hypertensive chronic kidney disease, stage 3a. Which codes are reported?

  1. I10 and N18.31
  2. I12.9 and N18.31 Correct answer.
  3. I12.9 and N18.9
  4. I13.10 and N18.31

Explanation

Hypertensive chronic kidney disease with stage 1 through 4 CKD is reported with I12.9 plus an additional code from N18 identifying the stage, here N18.31. The hypertension is not coded separately with I12.9.

Question 35Medical Coding (ICD-10-CM diagnosis coding)

A patient with a chronic pancreatic disorder develops diabetes, and the provider documents diabetes mellitus due to the underlying condition. How are the codes sequenced?

  1. E08.- only
  2. E11.9 only
  3. The underlying pancreatic disorder first, then E08.- Correct answer.
  4. E08.- first, then the pancreatic disorder

Explanation

Diabetes mellitus due to an underlying condition is classified to E08, which carries a Code first note requiring the underlying condition to be sequenced first. The E08 code is then reported as an additional diagnosis.

Question 36Medical Coding (ICD-10-CM diagnosis coding)

A patient with active multiple myeloma has anemia documented as due to the malignancy. How are the codes reported?

  1. The myeloma code first, then the anemia code Correct answer.
  2. The anemia code first, then the myeloma code
  3. The anemia code alone
  4. The myeloma code alone

Explanation

Anemia in neoplastic disease is classified to D63.0, which carries a Code first note for the underlying neoplasm. The malignancy is sequenced first and the anemia code follows.

Question 37Medical Coding (ICD-10-CM diagnosis coding)

An asymptomatic patient with documented HIV-positive status is seen for a routine visit, and no HIV-related illness is documented. Which code is assigned?

  1. R75
  2. Z11.4
  3. B20
  4. Z21 Correct answer.

Explanation

Z21 is used when a patient is documented as HIV positive but has no symptoms or HIV-related illness. B20 requires documentation of an HIV-related condition.

Question 38Medical Coding (ICD-10-CM diagnosis coding)

A patient is diagnosed with lumbar spinal stenosis with neurogenic claudication. Which code is assigned?

  1. M48.06
  2. M48.061
  3. M48.062 Correct answer.
  4. M54.50

Explanation

Codes in category M48.06 require a sixth character: 1 when neurogenic claudication is absent and 2 when it is present. Because claudication is documented, M48.062 is assigned.

Question 39Medical Coding (ICD-10-CM diagnosis coding)

A patient who quit smoking three years ago reports no current tobacco use, and the provider documents a history of tobacco use. Which code is assigned?

  1. F17.210
  2. Z72.0
  3. Z87.891 Correct answer.
  4. F17.200

Explanation

Z87.891 reports a personal history of nicotine dependence and is used when the patient no longer uses tobacco. Active dependence is reported with a code from F17.

Question 40Medical Coding (ICD-10-CM diagnosis coding)

A patient returns for follow-up care after a total hip replacement and is healing normally with no complications. Which code is assigned?

  1. Z48.01
  2. M25.551
  3. Z96.641
  4. Z47.1 Correct answer.

Explanation

Z47.1 reports aftercare following joint replacement surgery and is first-listed for routine follow-up of the replaced joint. It is used when the encounter is for aftercare and no complication is present.

Question 41Medical Coding (ICD-10-CM diagnosis coding)

A patient with prostate cancer is admitted solely to receive a course of radiation therapy. What is the first-listed code?

  1. Z51.11
  2. Z51.5
  3. Z51.0 Correct answer.
  4. C61

Explanation

When the encounter is solely for radiation therapy, the radiation therapy encounter code Z51.0 is first-listed, with the malignancy reported as an additional code. The same principle applies to chemotherapy encounters.

Question 42Medical Coding (ICD-10-CM diagnosis coding)

A patient with terminal cancer is admitted specifically for palliative care to manage pain. What is the first-listed code?

  1. G89.3
  2. Z51.0
  3. Z51.89
  4. Z51.5 Correct answer.

Explanation

Z51.5 is first-listed when the encounter or admission is specifically for palliative care. The underlying condition and any pain code are reported as additional diagnoses.

Question 43Medical Coding (ICD-10-CM diagnosis coding)

A 45-year-old man whose father had colon cancer presents without symptoms for a screening colonoscopy. Which codes are reported?

  1. Z12.11 and Z80.0 Correct answer.
  2. Z12.11 only
  3. Z80.0 only
  4. Z80.0 and Z85.038

Explanation

The screening code Z12.11 is first-listed because the encounter is for screening, and Z80.0 is added to identify the family history of malignant neoplasm of the digestive organs. A personal-history code is not used because the patient has not had the disease.

Question 44Medical Coding (ICD-10-CM diagnosis coding)

A patient with mild persistent asthma is seen for an acute exacerbation. Which code is assigned?

  1. J44.1
  2. J45.41
  3. J45.31 Correct answer.
  4. J45.30

Explanation

J45.31 identifies mild persistent asthma with acute exacerbation in a single combination code. The classification distinguishes intermittent and persistent asthma by severity and whether an exacerbation is present.

Question 45Medical Coding (ICD-10-CM diagnosis coding)

A woman at 10 weeks' gestation is admitted with hyperemesis gravidarum accompanied by metabolic disturbance. Which code is assigned?

  1. O21.9
  2. R11.2
  3. O21.1 Correct answer.
  4. O21.0

Explanation

O21.1 reports hyperemesis gravidarum with metabolic disturbance, which is more specific than the code for mild or unspecified vomiting of pregnancy. A code from Z3A is added to identify the weeks of gestation.

Question 46Medical Coding (ICD-10-CM diagnosis coding)

A patient with AIDS is admitted with Pneumocystis jirovecii pneumonia. How should the codes be sequenced?

  1. The pneumonia code alone
  2. The pneumonia code first, followed by B20
  3. B20 first, followed by the pneumonia code Correct answer.
  4. B20 alone

Explanation

For HIV disease with a related condition, B20 is sequenced first and the code for the manifestation follows. Coding the manifestation first would reverse the required order.

Question 47Medical Coding (ICD-10-CM diagnosis coding)

A patient with end-stage renal disease who depends on chronic hemodialysis is seen for a visit unrelated to dialysis. Which codes document the renal status?

  1. N18.9 and Z49.01
  2. N18.6 only
  3. N18.6 and Z99.2 Correct answer.
  4. N18.5 and Z99.2

Explanation

End-stage renal disease is classified to N18.6, and Z99.2 is added to indicate dependence on renal dialysis. The dialysis status code is reported on encounters even when dialysis is not performed.

Question 48Medical Coding (ICD-10-CM diagnosis coding)

A patient with metastatic bone disease sustains a pathologic fracture through a metastatic lesion of the femur. How are the codes sequenced?

  1. The fracture code first, then the neoplasm code.
  2. The neoplasm code first, then the pathologic fracture code. Correct answer.
  3. Only the fracture code is reported.
  4. Only the neoplasm code is reported.

Explanation

Pathologic fracture in neoplastic disease codes in category M84.5 carry a Code first note for the underlying neoplasm. The malignancy is sequenced first and the fracture code follows.

Question 49Medical Coding (ICD-10-CM diagnosis coding)

A woman with type 1 diabetes who is at 20 weeks' gestation is seen for management of her diabetes in pregnancy, and the provider documents pre-existing type 1 diabetes. Which code identifies the diabetes?

  1. O24.019
  2. O24.419
  3. E10.9
  4. O24.012 Correct answer.

Explanation

Pre-existing type 1 diabetes mellitus in pregnancy is classified to O24.0, with a sixth character identifying the trimester; 2 denotes the second trimester. A code from Z3A is added to document the weeks of gestation.

Question 50Medical Coding (ICD-10-CM diagnosis coding)

A patient has a third-degree burn of the right forearm and a second-degree burn of the same right forearm. How are these reported?

  1. Only the third-degree burn code for the forearm. Correct answer.
  2. Both the second-degree and third-degree burn codes for the forearm.
  3. Only the second-degree burn code for the forearm.
  4. One code for burn of the forearm, degree unspecified.

Explanation

When burns of different degrees are documented at the same site, only the code for the highest degree of burn at that site is reported. Separate codes are used only when different sites are involved.