Assesment Competency ICD 10 For Coders
Assesment Competency ICD 10 For Coders
Competency
Assessment
for Coders
ICD-10-CM & ICD-10-PCS
ISBN: 978-1-60146-875-8
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Contents
Jones, who has more than 25 years of coding and consulting experience, began preparing for
ICD-10 by returning to school. She completed University of Phoenix online courses in anatomy,
physiology, and pathophysiology. These biomedical courses are essential for successful under-
standing and application of ICD-10 diagnosis and procedure codes. She also attended the Third
Annual ICD-10-CM Summit in Baltimore and the ICD-10-CM Academy in Boston.
Brown’s more than 30 years of experience provides expertise across a broad continuum in the
healthcare industry, including hospitals, physician offices/clinics, insurance carriers, surgery
centers, the Veterans Administration, software/equipment companies, law firms, and consult-
ing companies.
Brown’s focus has been coding, beginning with ICD-8-CM. She specializes in clinical documenta-
tion integrity; audits involving all levels in inpatient, outpatient, and physician settings; denial
management, including Recovery Audit Contractors; education and training; computer-assisted
coding; health information management operations; revenue cycle; and compliance. The ultimate
goal of her work is complete documentation to support the most accurate codes, sustainable
through time as the healthcare industry transitions to an increasingly electronic world and pre-
pares for ICD-10.
A frequent speaker, Brown has addressed diverse audiences, including specialty associations,
national organizations such as AHIMA and the Association of Clinical Documentation Specialists,
and several state and regional AHIMA and AAPC chapters.
Brown entered the health information management field as an accredited record technician. She
attended Moraine Valley Community College in Palos Hills, IL, and holds a bachelor’s degree in
health information management from the University of Central Florida in Orlando.
Paul L. Dickson of Cornelia, GA, has provided independent coding and billing compliance con-
sulting services to a variety of organizations since 1999. He specializes in ICD-9-CM and CPT®
coding for inpatient and outpatient services.
Since 2003, his focus has been clinical documentation improvement training programs and audits.
Dickson has provided education programs and coding compliance audits for hospitals (inpatient)
and physicians (E/M). His services as a consultant have included risk opportunity coding assess-
ment; compliance audits; and clinical education for physicians and office and hospital staff.
Dickson has provided consulting services for a variety of organizations, including DCBA, Inc.,
in Atlanta and numerous healthcare facilities. A graduate of the Medical College of Georgia in
Augusta, Dickson completed his surgical internship and residency at the Medical College of
Georgia Hospital and Clinics and later practiced in Demorest, GA. He is a frequent contributor
to professional publications that address various coding topics.
ICD-10-CM: 35 Questions
Editor’s note: Answers to the questions in this chapter include explanations that rely on and provide
information from the following online sources.
Access the ICD-10-CM Official Guidelines for Coding and Reporting 2011 at www.cdc.gov/nchs/data/
icd9/10cmguidelines2011_FINAL.pdf.
1. Official coding guidelines instruct coders to code only confirmed cases of HIV infec-
tion/illness. Which of the following statements is true with respect to the “con-
firmed” reference in this guideline?
b. An infectious disease specialist must document that the patient has an HIV-related illness.
c. Confirmation does not require documentation of positive serology or culture for HIV.
The introduction to the ICD-10-CM Table of Neoplasms states that codes listed with a dash after them
have a required .
3. How should the encounter be coded when an outpatient is seen for a pathological
fracture due to neoplasm and the focus of the treatment is the neoplasm?
a. A code from subcategory M84.5-, Pathological fracture in neoplastic disease, should be sequenced
first, followed by the code for the neoplasm.
b. A neoplasm code should be sequenced first, followed by a code from M84.5- for the
pathological fracture.
c. A code from subcategory M84.5-, Pathological fracture in neoplastic disease, is the only
code required.
d. A code from subcategory M84.5-, Pathological fracture in neoplastic disease, should be sequenced
first, followed by a personal history of neoplasm code.
4. Which Excludes note appears in the ICD-10-CM Tabular List of Diseases and
Injuries at code D63.0, Anemia in neoplastic disease?
__________________________________________________________________________
5. Refer to the “Use additional code” note that appears in the ICD-10-CM Tabular List
of Diseases and Injuries for code E10.621. Which of the following is not a valid code
combination for type 1 diabetes mellitus with right foot ulcer?
The ICD-10-CM Tabular List of Diseases and Injuries includes a note that explains the difference
between mild, moderate, and severe nonproliferative diabetic retinopathy.
True
False
7. When provider documentation refers to use, abuse, and dependence of the same
substance (e.g., alcohol, opioid, cannabis), only one code should be assigned to
identify the pattern of use based on the following hierarchy. List this hierarchy.
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
8. Which Excludes note applies to all codes in ICD-10-CM Chapter 5, Mental and
Behavioral Disorders?
__________________________________________________________________________
9. How many sequelae codes does the ICD-10-CM Tabular List of Diseases and Injuries
for Chapter 6, Diseases of the Nervous System, include?
a. One
b. Two
c. Three
d. Four
10. Which disease is classified as “with early onset” and “with late onset” in Chapter 6,
Diseases of the Nervous System?
__________________________________________________________________________
11. Which of the following is not a subcategory heading in the ICD-10-CM Tabular List
of Diseases and Injuries for Chapter 7, Diseases of the Eye and Adnexa, in the H59
coding range?
12. Which of the following complications would be reported with ICD-10-CM code
H95.88 and an additional code to further specify the disorder?
b. Postmastoidectomy granulation
d. Postmastoidectomy pneumocephalus
13. Assign the appropriate code(s) for hypertensive heart and chronic kidney disease,
with acute on chronic combined systolic congestive and diastolic congestive heart
failure, and stage 4 chronic kidney disease.
__________________________________________________________________________
14. Which of the following guidelines is not correct for ICD-10-CM myocardial
infarction (MI) coding?
a. A code from category I22 must be used in conjunction with a code from category I21.
c. Code I22 should be sequenced after the I21 code if the subsequent MI occurs during the encounter
for the initial MI.
d. Code I22 should not be used if the subsequent MI occurs intraoperatively during cardiac surgery;
use only code I97.790.
15. How many cardiac arrest codes are there in the ICD-10-CM Tabular List of Diseases
and Injuries for Chapter 9, Diseases of the Circulatory System?
a. Five
b. Six
c. Seven
d. Eight
16. Which of the following conditions is classified as “mild intermittent,” “mild persis-
tent,” “moderate persistent,” and “severe persistent” in ICD-10-CM?
a. Sinusitis
b. Pharyngitis
c. Asthma
d. Tonsillitis
Case Study 1
Assign all applicable ICD-10-CM diagnosis codes (including all appropriate external cause of injury
codes) for the following case.
Subjective: This is a 78-year-old female here for a lacerated leg and arm. She is visiting from Texas;
while she was at the local airport, she fell down several stairs on the escalator. She lacerated her
left shin and left elbow. She had no loss of consciousness, and no other injuries were sustained.
She was attended by a paramedic, but then declined treatment and was brought here by her family
to be seen. She denies any headache. She denies any numbing or tingling. No other injuries were
sustained. She complains of left elbow pain and left lower-leg pain.
Objective:
Vital signs: Temperature: 98.6°F; respirations: 12; pulse oximetry: 94; blood pressure: 151/81.
General: This is an alert, elderly female. She is in no acute distress.
Skin: Examination of her left elbow reveals two 1-cm lacerations noted, not actively bleeding, just
at the olecranon. There is no tenderness to palpation around the elbow. She has full range of motion.
Her left lower extremity reveals a significant 5cm × 7cm area of avulsion of the skin, lateral aspect
of her lower leg, superior to the lateral malleolus. It is down to the fatty tissue. It is tender to pal-
pation. It is not actively bleeding. She has no tenderness to palpation around her ankle or leg. She
has good range of motion. Her neurovascular is intact.
Diagnostics: X-ray of the left elbow and the right lower extremity tibia, fibula, and ankle all appear
negative. No evidence of a fracture. Radiologist is to overread.
Assessment:
Plan: I placed lidocaine, epinephrine, and tetracaine, and subsequently infiltrated a total of 6 cc of
1% plain xylocaine in the left elbow lacerations and around the left lower-extremity laceration. The
left elbow lacerations were sutured with a total of five 4-0 Prolene™ sutures with good wound edge
approximation. The left lower extremity was then sutured with multiple sutures to approximate the
skin edges. There was a fairly large area, approximately the size of a quarter, of the skin that had
been avulsed and was not able to be approximated. The skin that was remaining was approximated
with multiple 4-0 Prolene® sutures. On the remainder of that area, Dermabond® was placed. It was
dressed with Vaseline® gauze. An IV was started prior to the procedure. She was given Demerol®
50 mg and Phenergan® 25 mg with adequate analgesia. She was also given Ancef® 1 g IV times
one, as well as an adult DT. The wounds were then dressed, as noted previously. She was given
Keflex® 500 mg t.i.d., #40, Lortab® 5/500, 1–2 q. 4 hours p.r.n. pain, #20, with one refill, and
Silvadene® 1% to be applied to the lower extremity for dressing changes twice daily. She is to
follow up with her relative’s primary care physician (PCP) or return here in two to three days for
a recheck/reassessment. The sutures are to be removed in seven to 10 days. Her current medica-
tions were reviewed, and she is to continue them as prescribed. Wound care instructions were
given. She is to follow up sooner if worsening symptoms occur. She understands and agrees with
the t reatment plan. She was dismissed in stable condition. There were no complications during
her urgent care stay.
Case Study 2
Assign all applicable ICD-10-CM diagnosis codes (including all appropriate external cause of injury
codes) for the following case.
MEDICAL CLINIC
VISIT NOTE
History of present illness: The patient is a 74-year-old white male who presents to clinic with a
two-day history of hematuria and dysuria.
Current medications: Zocor®; the patient also took one tablet of ciprofloxacin approximately
four hours ago.
Review of systems:
Constitutional: The patient had no fever or chills.
Musculoskeletal: The patient complains of some left low-back pain; however, he had a deep tissue
massage approximately three days ago and believes his back pain may be related to this.
Physical examination:
Vital signs: Blood pressure: 142/92; pulse: 51; temperature: 97.8°F; respirations: 16; pulse oximetry
on room air: 97%; weight: 210 pounds
General: The patient is in no acute distress. On examination of his back, the patient has some
tenderness of paraspinous muscles on left lower back.
Laboratory: The patient’s urinalysis reveals a large amount of blood and a small amount
of leukocytes.
Assessment:
Plan:
1. The patient is placed on ciprofloxacin 500 mg, one p.o. b.i.d. for seven days, #14
ICD-10
Competency Assessment for Coders
ICD-10-CM & ICD-10-PCS
Lolita M. Jones, RHIA, CCS
The ICD-10 Competency Assessment for Coders: ICD-10-CM &
ICD-10-PCS features 70 questions and answers and 30 case studies with
answers and explanations developed to help you kick off your training
program and see where your coding and HIM staff need focused train-
ing efforts. You’ll identify key areas of your staff members’ understanding
of ICD-10 that your training program will need to address. Each package
includes five workbooks and one answer key.
The ICD-10 Training Toolkit provides the building blocks for your
training programs for physicians, as well as coding, HIM, documentation,
and billing professionals in both inpatient and outpatient settings.
ICD10CMPCS
Answer key
Contents
Answer Key
Question 1
Correct answer:
c. Confirmation does not require documentation of positive serology or culture for HIV.
Rationale:
ICD-10-CM Official Guidelines for Coding and Reporting 2011, p. 16, at www.cdc.gov/nchs/data/icd9/
10cmguidelines2011_FINAL.pdf, state:
Code only confirmed cases of HIV infection/illness. This is an exception to the hospital inpatient
guideline Section II, H. In this context, “confirmation” does not require documentation of positive
serology or culture for HIV; the provider’s diagnostic statement that the patient is HIV positive, or
has an HIV-related illness is sufficient.
Question 2
Correct answer:
Rationale:
Refer to the following note at the beginning of the ICD-10-CM Table of Neoplasms:
Codes listed with a dash -, following the code have a required 5th character for laterality.
The tabular list must be reviewed for the complete code.
Select icd10cm_neoplasm_2011.
Question 3
Correct answer:
b. A neoplasm code should be sequenced first, followed by a code from M84.5- for the
pathological fracture.
Rationale:
ICD-10-CM Official Guidelines for Coding and Reporting 2011, p. 27, state:
If the focus of treatment is the neoplasm with an associated pathological fracture, the neoplasm
code should be sequenced first, followed by a code from M84.5- for the pathological fracture.
Question 4
Correct answer:
Excludes1
Rationale:
In the 2011 ICD-10-CM Tabular List of Diseases and Injuries, this Excludes1 note appears below
code D63.0.
Question 5
Correct answer:
Rationale:
The following note appears in the ICD-10-CM Tabular List of Diseases and Injuries:
The additional code notes include “an unspecified” heel. Code L97.409 does not specify right or left
laterality: Non-pressure chronic ulcer of unspecified heel and midfoot with unspecified severity. The
other codes in the range specify the right foot, as the following descriptions indicate:
L97.419 Non-pressure chronic ulcer of right heel and midfoot with unspecified severity
L97.511 Non-pressure chronic ulcer of other part of right foot limited to breakdown of skin
L97.519 Non-pressure chronic ulcer of other part of right foot with unspecified severity
Select icd10cm_Tabular.
Refer to Chapter 12, Diseases of the Skin and Subcutaneous Tissue (L00–L99).
Question 6
Correct answer:
False
Rationale:
This information does not exist in the ICD-10-CM Tabular List of Diseases and Injuries nor in the
ICD-10-CM Official Guidelines for Coding and Reporting 2011. Attending physicians will need to
document the severity of nonproliferative diabetic retinopathy to facilitate assignment of the most
specific code.
Question 7
Correct answer:
• If both use and abuse are documented, assign only the code for abuse
• If both abuse and dependence are documented, assign only the code for dependence
• If use, abuse, and dependence are all documented, assign only the code for dependence
• If both use and dependence are documented, assign only the code for dependence
Rationale:
ICD-10-CM Official Guidelines for Coding and Reporting 2011, p. 31, state:
When the provider documentation refers to use, abuse and dependence of the same substance
(e.g. alcohol, opioid, cannabis, etc.), only one code should be assigned to identify the pattern of
use based on the following hierarchy:
• If both use and abuse are documented, assign only the code for abuse
• If both abuse and dependence are documented, assign only the code for dependence
• If use, abuse and dependence are all documented, assign only the code for dependence
• If both use and dependence are documented, assign only the code for dependence.
Question 8
Correct answer:
Excludes2: symptoms, signs, and abnormal clinical laboratory findings, not elsewhere
classified (R00–R99)
Rationale:
The following note appears at the beginning of Chapter 5. Therefore, it applies to all codes in the
F01–F99 code range, which is the entire listing of codes in the chapter.
Chapter 5
Mental and behavioral disorders (F01–F99)
Excludes2: symptoms, signs and abnormal clinical laboratory findings, not elsewhere
classified (R00–R99)