22 ICD-10-CM Guidelines & Conventions Practice Questions & Answers

1. 1. A coder locates a main term in the ICD-10-CM Alphabetic Index and finds a code listed beside it. What do the Official Guidelines require the coder to do next?

   • A.Compare the code with the payer's coverage policy and assign it if that policy lists the code as payable.
   • B.Verify the code in the Tabular List and follow every instructional note found there before assigning it.✓ Answer
   • C.Add the placeholder character X to the Index code so that it reaches the required seven-character length.
   • D.Assign the code exactly as the Index lists it, because the Index entry already matches the provider's wording.

   ICD-10-CM coding is a mandatory two-step process: locate the term in the Alphabetic Index, then verify the code in the Tabular List. Only the Tabular carries the Excludes notes, seventh-character requirements and other instructions that can change or invalidate the code, so a code taken from the Index alone has never been verified. Payer policy affects payment, not code selection.

   Source: ICD-10-CM Official Guidelines for Coding and Reporting, Section I.A.1 and I.B.1 (use both the Alphabetic Index and the Tabular List)Report a problem with this question

2. 2. A code in the Tabular List carries an Excludes2 note naming another condition, and the physician documents both conditions at the same office visit. How should this be reported?

   • A.Report only the code carrying the note, because Excludes2 bars the two conditions from ever appearing together.
   • B.Report both codes, because Excludes2 means the excluded condition is not part of this code but may coexist.✓ Answer
   • C.Report both codes only after querying the provider to confirm that the two conditions are clinically unrelated.
   • D.Report only the excluded condition's code, because an Excludes2 note gives that condition sequencing priority.

   Excludes2 means "not included here": the excluded condition is not part of the condition the code represents, but a patient may have both at the same time. When documentation supports both, both codes are reported together, and no query or modifier is needed. It is Excludes1, not Excludes2, that means "not coded here."

   Source: ICD-10-CM Official Guidelines, Section I.A.12.b (Excludes2 notes)Report a problem with this question

3. 3. A code carries an Excludes1 note pointing to a second code, but the physician documents the two conditions as unrelated to each other. What do the guidelines direct?

   • A.Report both codes, because the Excludes1 note does not apply when the two conditions are unrelated.✓ Answer
   • B.Report only the first condition, because an Excludes1 note bars the pair under every circumstance.
   • C.Report both codes and append a modifier showing that the two conditions arose from separate causes.
   • D.Report an unspecified code instead, because an Excludes1 conflict makes both specific codes invalid.

   Excludes1 normally means "not coded here" because the two conditions cannot occur together, but the guidelines create an explicit exception: when the two conditions are unrelated to each other, both may be reported. When it is not clear whether the conditions are related, the coder queries the provider rather than guessing. Modifiers are CPT/HCPCS constructs and never resolve an ICD-10-CM Excludes conflict.

   Source: ICD-10-CM Official Guidelines, Section I.A.12.a (Excludes1 notes and the unrelated-condition exception)Report a problem with this question

4. 4. The record documents a specific form of a disease, but ICD-10-CM provides no code for that particular form. Which Index entry does the coder use, and why?

   • A.The NOS entry, because that abbreviation marks any code that can be verified only in the Alphabetic Index.
   • B.The NEC entry, because that abbreviation marks the unspecified code used when documentation lacks detail.
   • C.The NOS entry, because 'not otherwise specified' covers documented detail the classification cannot code.
   • D.The NEC entry, because 'not elsewhere classifiable' covers documented detail the classification cannot code.✓ Answer

   The two abbreviations turn on where the gap lies. NEC ("not elsewhere classifiable," the other-specified entry) is used when the documentation is specific but the classification has no code for that specificity. NOS is the unspecified entry, used when the record itself lacks the detail needed for a more precise code. Candidates routinely reverse the pair.

   Source: ICD-10-CM Official Guidelines, Section I.A.6.a (Alphabetic Index abbreviations NEC and NOS)Report a problem with this question

5. 5. A code requires a seventh character, but the applicable subcategory provides only five characters. What must the coder do to report a valid code?

   • A.Report the five-character code alone, since seventh characters apply only to seven-character subcategories.
   • B.Move the seventh character into the sixth position so that no character position is left empty.
   • C.Report the five-character code and add a separate code that identifies the episode of care.
   • D.Fill the sixth position with placeholder X so the seventh character occupies the seventh position.✓ Answer

   The seventh character must always sit in the seventh position of the code. When the subcategory is shorter than six characters, the placeholder X fills every empty position so the applicable seventh character lands correctly. A code that requires a seventh character is invalid without it, and moving the character to another position produces a code that does not exist.

   Source: ICD-10-CM Official Guidelines, Sections I.A.4 (placeholder character) and I.A.5 (7th characters)Report a problem with this question

6. 6. Two weeks after a fall, a patient sees an orthopedic surgeon for the first time and undergoes surgical repair of the fracture. Which seventh character applies to the fracture code?

   • A.'D,' because the surgeon is treating the patient after an earlier emergency department encounter.
   • B.'D,' along with an aftercare Z code describing the surgical care given for the healing fracture.
   • C.'S,' because the surgery addresses a condition that arose later as a result of the original injury.
   • D.'A,' because the patient is receiving active treatment of the injury at this particular encounter.✓ Answer

   Seventh character A means active treatment of the injury, not "the patient's first visit." Surgical repair, evaluation by a new physician and emergency care are all active treatment, so A applies however many encounters preceded it. D covers routine healing and recovery afterward, and aftercare Z codes are never used for injuries because the seventh character already conveys the episode.

   Source: ICD-10-CM Official Guidelines, Section I.C.19.a (7th characters for Chapter 19 injury codes)Report a problem with this question

7. 7. A patient is seen in the office for a scar contracture that resulted from a burn sustained three years ago. How are the codes sequenced?

   • A.The burn code with seventh character 'D' first, then the code for the scar contracture.
   • B.Only the burn code with seventh character 'S', which already covers the residual.
   • C.The code for the scar contracture first, and then the burn code with seventh character 'S'.✓ Answer
   • D.The burn code with seventh character 'S' first, then the code for the scar contracture.

   A sequela is the residual effect left after the acute phase of an injury or illness has ended, and there is no time limit on when it may appear. The residual condition being treated is sequenced first and the code for the original cause with seventh character S second, so the sequela code is never first-listed. Both codes are required, since the S code alone does not identify the residual.

   Source: ICD-10-CM Official Guidelines, Section I.B.10 (sequela) and I.C.19.a (7th character S)Report a problem with this question

8. 8. A physician's office note concludes: "Right lower quadrant abdominal pain; rule out appendicitis." What diagnosis is reported for this outpatient encounter?

   • A.An encounter code for a suspected condition ruled out, with the abdominal pain reported second.
   • B.The appendicitis first and the abdominal pain second, reflecting the physician's clinical impression.
   • C.The appendicitis, because a documented rule-out diagnosis is coded as though it were established.
   • D.The abdominal pain, because a rule-out diagnosis is never coded as confirmed in this setting.✓ Answer

   In the physician office and hospital outpatient setting, a diagnosis documented as probable, suspected, questionable, rule out, compatible with or working is not coded. The coder reports the condition to the highest degree of certainty established at that visit, which here is the sign — the abdominal pain. Coding an uncertain diagnosis as confirmed is the inpatient rule, and it is the classic wrong answer.

   Source: ICD-10-CM Official Guidelines, Section IV.H (uncertain diagnosis, outpatient)Report a problem with this question

9. 9. Which statement correctly describes how the reported diagnosis is selected for a physician office encounter?

   • A.The principal diagnosis is the chronic condition the patient has carried for the longest time.
   • B.The principal diagnosis is the condition established after study as occasioning the patient's visit.
   • C.The first-listed diagnosis is whichever documented condition carries the greatest severity of illness.
   • D.The first-listed diagnosis is the condition chiefly responsible for the services provided that day.✓ Answer

   Outpatient and physician-office coding uses the term first-listed diagnosis, defined as the condition chiefly responsible for the services provided at that encounter. The term principal diagnosis comes from the UHDDS definition, which applies to inpatient admissions and does not govern physician office or hospital outpatient reporting. Severity of illness does not drive the selection.

   Source: ICD-10-CM Official Guidelines, Sections IV.A and IV.G (selection of the first-listed condition)Report a problem with this question

10. 10. A patient with documented acute bronchitis is treated for cough and wheezing, and the same note records ankle pain from an unrelated fall. What is reported?

    • A.Bronchitis, cough, wheezing and the ankle pain, since every condition in the note is reported.
    • B.Bronchitis only, since any other complaint addressed at the same visit is bundled into it.
    • C.Cough and wheezing only, since symptoms take precedence over a diagnosis in the office setting.
    • D.Bronchitis and the ankle pain, since cough and wheezing are integral to the bronchitis itself.✓ Answer

    Signs and symptoms that are routinely associated with a disease process are integral to it and are not coded separately once the definitive diagnosis is established; cough and wheezing are integral to bronchitis. Conditions that are not routinely associated with that disease process, such as the ankle pain, are coded in addition because they are separately documented and affect the care given.

    Source: ICD-10-CM Official Guidelines, Sections I.B.5 and I.B.6 (conditions integral / not integral to a disease process)Report a problem with this question

11. 11. An established patient is treated for acute sinusitis. The record also lists type 2 diabetes managed with medication and an appendectomy performed ten years ago. Besides the sinusitis, what is reported?

    • A.The past appendicitis only, because prior surgery raises the complexity of the current visit.
    • B.Neither condition, because only the problem chiefly responsible for the visit may be reported.
    • C.The diabetes and the past appendicitis, because both belong to the patient's permanent record.
    • D.The diabetes only, because chronic conditions are reported while they are treated and managed.✓ Answer

    Chronic diseases treated on an ongoing basis may be reported as many times as the patient receives treatment for them, so the medication-managed diabetes is a valid secondary code. Conditions previously treated and no longer existing, such as the resolved appendicitis, are not coded; if the surgical history affected current care, a personal history code would be the appropriate secondary entry instead.

    Source: ICD-10-CM Official Guidelines, Sections IV.I (chronic diseases) and IV.J (code all documented coexisting conditions)Report a problem with this question

12. 12. A patient is referred for a chest x-ray because of a cough. The radiologist's signed interpretation, available when the claim is coded, documents pneumonia. What is reported?

    • A.The pneumonia alone, because the cough is integral to that confirmed radiologic diagnosis of the chest.✓ Answer
    • B.The cough first and the pneumonia second, because the cough prompted the referral for imaging.
    • C.A screening code first, with the pneumonia added as a secondary diagnosis for the encounter.
    • D.The cough alone, because the ordering physician has not confirmed the radiologist's finding.

    For a patient receiving diagnostic services only, the reason for the encounter is sequenced first, but when the physician's final interpretive report is available at the time of coding and confirms a definitive diagnosis, that diagnosis is coded and the related signs and symptoms are not coded in addition. A screening code does not apply because the study was ordered for a symptom.

    Source: ICD-10-CM Official Guidelines, Section IV.K (patients receiving diagnostic services only)Report a problem with this question

13. 13. A patient with a known malignancy presents solely for a chemotherapy session and develops nausea and vomiting during the treatment. How is the encounter sequenced?

    • A.The nausea and vomiting first, then the chemotherapy encounter code, then the malignancy.
    • B.The chemotherapy encounter code first, then the malignancy, then the nausea and vomiting.✓ Answer
    • C.The malignancy first, then the chemotherapy encounter code, then the nausea and vomiting.
    • D.The nausea and vomiting first, then the malignancy, then the chemotherapy encounter code.

    When the encounter is solely for administration of chemotherapy, immunotherapy or radiation, the Z code for that therapy is first-listed and the malignancy is reported as a secondary code. Complications such as nausea and vomiting that develop during the same session do not displace it. Only when the patient is seen for the complication and no therapy is given does the complication become first-listed.

    Source: ICD-10-CM Official Guidelines, Section I.C.2.e.2 (encounter solely for administration of chemotherapy, immunotherapy or radiation)Report a problem with this question

14. 14. A cardiologist performs a preoperative clearance evaluation requested before a patient's elective hip replacement; the patient also has hypertension. How is the encounter sequenced?

    • A.The hip condition first, then the preprocedural examination code, then the hypertension.
    • B.The preprocedural examination code first, then the hip condition, then the hypertension.✓ Answer
    • C.The hypertension first, then the preprocedural examination code, then the hip condition.
    • D.The hip condition first, then the hypertension, with no preprocedural examination code.

    For a patient receiving a preoperative evaluation only, the preprocedural examination Z code is assigned as the first-listed diagnosis, followed by the condition that is the reason for the surgery, then any findings related to the preoperative evaluation. Reversing the first two codes misrepresents why the cardiologist saw the patient, since the encounter itself is the clearance, not treatment of the hip.

    Source: ICD-10-CM Official Guidelines, Section IV.M (patients receiving preoperative evaluations only)Report a problem with this question

15. 15. The Alphabetic Index offers a single code that identifies both a condition and its associated manifestation. What does the guideline require the coder to do?

    • A.Assign the combination code only if the provider explicitly links the condition and manifestation.
    • B.Assign the combination code and each component code, so that no documented detail is lost.
    • C.Assign the combination code alone, and do not additionally code its individual components.✓ Answer
    • D.Assign a separate code for each component, because two codes describe the encounter more fully.

    A combination code is a single code that classifies two diagnoses, or a diagnosis with an associated manifestation or complication. When the Index and Tabular support it, that code is assigned and multiple codes are not used for its component parts; reporting both the combination code and its components is unbundling. A secondary code is added only when the combination code lacks the necessary specificity.

    Source: ICD-10-CM Official Guidelines, Section I.B.9 (combination codes)Report a problem with this question

16. 16. An office note lists "type 2 diabetes mellitus" and "chronic kidney disease, stage 3" with no statement linking the two. How does ICD-10-CM treat the relationship?

    • A.A link is presumed only after the provider answers a query stating that the conditions are related.
    • B.A link is presumed only when the patient's diabetes is documented as requiring insulin treatment.
    • C.No link is presumed, so the diabetes and the kidney disease are reported as two unrelated codes.
    • D.A causal link is presumed, so a diabetes with chronic kidney disease code plus the stage is used.✓ Answer

    The word "with" in a code title, in the Index or in a Tabular note means "associated with" or "due to," and the classification presumes that causal relationship. Chronic kidney disease is indented under the "with" subterm for diabetes, so the diabetes-with-CKD combination code is assigned without any physician linking statement, plus a code for the CKD stage. Only documentation stating the conditions are unrelated defeats the presumption.

    Source: ICD-10-CM Official Guidelines, Sections I.A.15 ("with") and I.C.4.a.2 (type of diabetes and its complications)Report a problem with this question

17. 17. A coder scanning the subterms under the main term "Diabetes" in the Alphabetic Index cannot find "gastroparesis" in the alphabetical list. Why?

    • A.Subterms following 'with' appear only in the Tabular List, never under a main term in the Index.
    • B.Subterms following 'with' appear only under the manifestation's own main term elsewhere in the Index.
    • C.Subterms following 'with' are placed immediately after the main term, before the alphabetical list.✓ Answer
    • D.Subterms following 'with' are printed at the end of the entry, after all other subterms are listed.

    In the Alphabetic Index the term "with" is sequenced immediately after the main term or subterm it modifies, not in alphabetical order with the other subterms. A coder who searches only the alphabetical run therefore misses the entire "with" block and may wrongly conclude that no combination entry exists for the manifestation.

    Source: ICD-10-CM Official Guidelines, Section I.A.15 ("with" — Index sequencing)Report a problem with this question

18. 18. A physician documents essential hypertension and stage 3 chronic kidney disease and says nothing about causation. How is this coded?

    • A.A secondary hypertension code plus a stage code, since the kidney disease is the underlying cause.
    • B.A hypertensive chronic kidney disease code plus a code for the stage, since the link is presumed.✓ Answer
    • C.Separate codes for the hypertension and for the kidney disease, since no causal link was documented.
    • D.A hypertensive chronic kidney disease code by itself, since it already identifies the disease stage.

    ICD-10-CM presumes a causal relationship between hypertension and chronic kidney disease whenever both are documented, so the hypertensive chronic kidney disease category is assigned along with an additional code identifying the CKD stage. The two are coded separately only when the provider states the kidney disease is unrelated to the hypertension. Secondary hypertension applies only when another condition causes the hypertension.

    Source: ICD-10-CM Official Guidelines, Section I.C.9.a.2 (hypertensive chronic kidney disease)Report a problem with this question

19. 19. A patient whose primary breast carcinoma was previously treated now undergoes an excision directed only at a metastatic lung lesion. What is first-listed?

    • A.The secondary lung malignancy, because treatment at this encounter is directed at that site.✓ Answer
    • B.A neoplasm of unspecified behavior of lung, because the metastasis lacks a pathology report.
    • C.The primary breast malignancy, because a primary site always outranks a metastatic site.
    • D.The personal history of breast malignancy, because the primary tumor was treated earlier.

    Neoplasm sequencing follows the reason for the encounter: when treatment is directed at a secondary site, that secondary neoplasm is first-listed even though a primary malignancy exists or is documented as a personal history. "Unspecified behavior" is not a substitute for a documented metastasis; it applies only when the record does not state the behavior of the neoplasm.

    Source: ICD-10-CM Official Guidelines, Section I.C.2 (general neoplasm guidelines — treatment directed at a secondary site)Report a problem with this question

20. 20. Treatment for a condition is complete. The patient returns only so the physician can confirm the condition remains resolved, and no treatment is given. Which category of Z code applies?

    • A.A follow-up code, because the visit provides surveillance after treatment has been completed.✓ Answer
    • B.An aftercare code, because the visit continues care during the healing phase of the condition.
    • C.A screening code, because the visit tests a patient who has no current signs or symptoms.
    • D.A personal history code alone, because the condition no longer requires any surveillance.

    Follow-up codes describe continuing surveillance after treatment has been completed and the disease no longer exists. Aftercare codes describe care given during the healing or recovery phase, when treatment is still ongoing. A personal history code is commonly reported with the follow-up code to identify the resolved condition, and screening applies only to testing for disease in a patient with no symptoms and no prior diagnosis.

    Source: ICD-10-CM Official Guidelines, Section I.C.21.c.8 (follow-up) and I.C.21.c.7 (aftercare)Report a problem with this question

21. 21. A pregnant patient is seen for a condition that the physician documents as incidental to the pregnancy. How is the encounter coded?

    • A.The condition, plus the code showing that the pregnancy is incidental to this encounter.✓ Answer
    • B.An obstetric complication code first, with the condition reported as an additional code.
    • C.The routine prenatal supervision code first, with the condition reported as an additional code.
    • D.The condition alone, because pregnancy is reported only on the record for the delivery.

    Chapter 15 obstetric codes normally take sequencing priority over codes from other chapters, but that priority applies only when the pregnancy is affected by, or affects, the condition being treated. When the provider documents that the pregnancy is incidental to the encounter, the Z code for incidental pregnant state is used instead of an obstetric complication code, and the condition itself is reported.

    Source: ICD-10-CM Official Guidelines, Section I.C.15.a.1 (Chapter 15 sequencing priority and incidental pregnant state)Report a problem with this question

22. 22. A manifestation code in the Tabular List carries a "code first the underlying disease" note. What sequencing does that note require?

    • A.The underlying etiology is reported first and the manifestation is reported second.✓ Answer
    • B.Only the underlying etiology is reported, because it already includes the manifestation.
    • C.The manifestation is reported first and the underlying etiology is reported second.
    • D.Either sequence is acceptable, because the note gives no direction about code order.

    The etiology/manifestation convention requires the underlying condition to be sequenced first and the manifestation second, and the paired "code first" and "use additional code" notes enforce that order. In the Alphabetic Index the manifestation code appears in brackets in slanted type as a signal that it can never be first-listed. The note that gives no sequencing direction is "code also."

    Source: ICD-10-CM Official Guidelines, Section I.A.13 (etiology/manifestation convention: "code first", "use additional code", "in diseases classified elsewhere")Report a problem with this question

Practice questions based on the ICD-10-CM Official Guidelines for Coding and Reporting, the AMA CPT guidelines, the CMS HCPCS Level II system, and federal healthcare compliance law. CPC is a mark of the AAPC and CPT is a mark of the American Medical Association; this site is not affiliated with or endorsed by either. ICD-10-CM, CPT, and HCPCS Level II are revised every year, so these questions test coding rules and conventions rather than code values — always verify actual code selection against the current code books and your payer's published policy. Nothing here is medical, legal, or billing advice. About the CPC exam →