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

1. 1. A coder needs to assign a diagnosis code for a condition documented in the record. Which sequence of steps does the ICD-10-CM classification require?

   • A.Locate the term in the Alphabetic Index first, then verify the code in the Tabular List, being guided by the instructional notes found in both.✓ Answer
   • B.Begin in the Tabular List to find the body-system chapter, then use the Alphabetic Index only to confirm the choice.
   • C.Use the Alphabetic Index alone whenever it supplies what appears to be a complete code.
   • D.Either the Index or the Tabular List may serve as the starting point, as long as both are eventually consulted.

   The Alphabetic Index does not always provide the full code: laterality and any applicable 7th character can only be selected in the Tabular List, and a dash at the end of an Index entry signals that more characters are needed. Beginning the search in the Tabular List is expressly identified as a source of coding errors, which is why the Index-then-Tabular order is mandatory rather than a preference.

   Source: ICD-10-CM Official Guidelines for Coding and Reporting, Section I.B.1 (Locating a code) and Section IV.A (Selection of first-listed condition)Report a problem with this question

2. 2. A code in the Tabular List carries an Excludes1 note listing another condition. What does that note tell the coder?

   • A.The excluded code may be reported, but only after the code above the note.
   • B.Both codes may routinely be reported together whenever both conditions are documented.
   • C.The excluded code should never be reported at the same time as the code above the note, because the two conditions cannot occur together.✓ Answer
   • D.The excluded code should be reported instead of the code above the note.

   Excludes1 is a pure excludes note meaning 'NOT CODED HERE!' It is used where two conditions are mutually exclusive, such as a congenital versus an acquired form of the same disease, so reporting both would describe a clinically impossible picture. The note is about simultaneous reporting, not about sequencing or substitution.

   Source: ICD-10-CM Official Guidelines for Coding and Reporting, Section I.A.12.a (Excludes1)Report a problem with this question

3. 3. Which statement correctly describes an Excludes2 note?

   • A.The excluded condition is not part of the condition represented by the code above the note, but a patient may have both, so both codes may be reported together when documented.✓ Answer
   • B.The excluded code must always be sequenced before the code above the note.
   • C.The excluded condition can never be reported with the code above the note.
   • D.The excluded code replaces the code above the note whenever both conditions are documented.

   Excludes2 means 'Not included here' — the excluded condition is simply a different condition that the code above does not capture, not an impossible companion diagnosis. Because the two can coexist, the convention explicitly permits reporting both codes together when the documentation supports each one; it gives no sequencing instruction.

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

4. 4. A record documents two conditions that appear on opposite sides of an Excludes1 note, and the coder cannot tell from the documentation whether the two conditions are related. What is the correct handling?

   • A.Both codes may be reported if the two conditions are clearly unrelated to each other; when it is not clear whether they are related, query the provider.✓ Answer
   • B.Excludes1 admits no exceptions, so only one of the two codes may ever be reported.
   • C.Report both codes automatically; an Excludes1 note never actually blocks dual reporting.
   • D.Report only the code above the note and drop the other condition entirely.

   The guidelines build in one exception to Excludes1: when the two conditions are clearly unrelated to each other, both may appropriately be reported. Because that judgment depends on clinical relatedness rather than on the coder's assumption, the guidelines direct the coder to query the provider whenever the relationship is unclear.

   Source: ICD-10-CM Official Guidelines for Coding and Reporting, Section I.A.12.a (Excludes1 exception)Report a problem with this question

5. 5. An underlying disease code carries a 'use additional code' note, and the code for its body-system manifestation carries a matching 'code first' note. What sequencing do these paired notes require?

   • A.The manifestation is sequenced first because it is the reason the patient was seen.
   • B.The underlying etiology is sequenced first and the manifestation second.✓ Answer
   • C.Only the manifestation code is reported, since it already implies the underlying disease.
   • D.Either order is acceptable; the paired notes describe content, not sequence.

   This matched pair of notes is the etiology/manifestation convention, and its whole purpose is to dictate order: the classification requires the underlying condition to be sequenced first, followed by the manifestation. The same pairing appears in the Alphabetic Index, where the etiology code is listed first and the manifestation code follows in brackets, and the bracketed code is always sequenced second.

   Source: ICD-10-CM Official Guidelines for Coding and Reporting, Section I.A.13 (Etiology/manifestation convention)Report a problem with this question

6. 6. A code title in the Tabular List ends with the phrase 'in diseases classified elsewhere.' What does that phrase establish about how the code may be used?

   • A.It may be sequenced in either position depending on which condition was treated.
   • B.It may be reported as the first-listed code whenever the manifestation is the reason for the encounter.
   • C.It is a combination code that stands alone and needs no companion code.
   • D.It is a manifestation code that may never be reported as the first-listed or principal diagnosis and must follow the code for the underlying condition.✓ Answer

   The title itself is the signal that the code is a component of the etiology/manifestation convention, so the code has no meaning without the underlying disease that produced it. Codes with this title are never permitted as first-listed or principal diagnoses; they must be used with an underlying condition code and listed after it, regardless of which problem dominated the visit.

   Source: ICD-10-CM Official Guidelines for Coding and Reporting, Section I.A.13 (Etiology/manifestation convention, 'in diseases classified elsewhere')Report a problem with this question

7. 7. A code in the Tabular List carries a 'code also' note. How does this note differ from a 'code first' note?

   • A.A 'code also' note signals that two codes may be needed to fully describe the condition but gives no sequencing direction; the order depends on the circumstances of the encounter.✓ Answer
   • B.The code named in a 'code also' note must always be sequenced second.
   • C.The code named in a 'code also' note must always be sequenced first.
   • D.There is no difference; 'code also' and 'code first' are interchangeable wording for the same instruction.

   'Code first' and 'use additional code' are sequencing instructions built into the classification, whereas 'code also' addresses only completeness of the description. Because the note is silent on order, the coder decides sequencing from the circumstances of the encounter — which condition was chiefly responsible for the services provided.

   Source: ICD-10-CM Official Guidelines for Coding and Reporting, Section I.A.17 ('Code also' note)Report a problem with this question

8. 8. In the Alphabetic Index, a subterm links a chronic disease to a second condition using the word 'with.' The provider's note lists both conditions but never states that one is due to the other. How should the coder proceed?

   • A.Code them as unrelated conditions, since the provider did not document a link.
   • B.Code only the condition that appears as the main term and disregard the subterm.
   • C.Query the provider; the conditions may not be coded as related until an explicit link is documented.
   • D.Code them as related — the classification presumes a causal relationship for conditions linked by 'with' or 'in' — unless the documentation states they are unrelated or another guideline requires an explicitly documented linkage.✓ Answer

   The words 'with' and 'in' are interpreted to mean 'associated with' or 'due to' wherever they appear in a code title, in the Alphabetic Index, or in a Tabular instructional note, and the classification itself supplies the causal presumption. Provider linkage language is required only for conditions the classification has not linked, or where a specific guideline overrides the presumption.

   Source: ICD-10-CM Official Guidelines for Coding and Reporting, Section I.A.15 ('With')Report a problem with this question

9. 9. How do the abbreviations NEC and NOS differ in ICD-10-CM?

   • A.NEC means 'not elsewhere classifiable' and directs the coder to the 'other specified' code when the condition is documented but no specific code exists; NOS means 'not otherwise specified' and is the equivalent of unspecified.✓ Answer
   • B.NEC means the documentation lacks detail, while NOS points to the 'other specified' code for a documented but unlisted condition.
   • C.Both abbreviations are synonyms meaning that the documentation is insufficient to select a code.
   • D.NEC is used only in the Alphabetic Index and NOS only in the Tabular List, so the two never apply to the same encounter.

   The distinction turns on where the gap lies: with NEC the documentation is specific but the classification has no matching code, so the 'other specified' entry is used; with NOS the classification could be more specific but the record is not, so the unspecified entry is used. Both abbreviations appear in the Alphabetic Index and in the Tabular List, so the location does not distinguish them.

   Source: ICD-10-CM Official Guidelines for Coding and Reporting, Section I.A.6 (Abbreviations: Alphabetic Index and Tabular List)Report a problem with this question

10. 10. A patient develops a new condition during the recovery period following surgery. The operative and progress notes describe the condition but say nothing about whether the surgery caused it. What does the classification require?

    • A.Conditions that develop after surgery are not coded at all during the postoperative period.
    • B.Assign a complication code only if the provider literally uses the word 'complication' in the record.
    • C.Do not assume a complication: a cause-and-effect relationship between the care and the condition must be supported by the documentation, and the provider should be queried when that relationship is unclear.✓ Answer
    • D.Assign a complication-of-care code, because any condition arising after surgery is by definition a complication.

    Not every condition that occurs during or after medical care is a complication; the classification requires a documented cause-and-effect relationship and evidence that the condition is clinically significant. At the same time, the provider need not use the word 'complication' — documentation such as an operative note showing the condition altered the course of surgery can support the code — so the coder's duty is to query rather than to infer either way.

    Source: ICD-10-CM Official Guidelines for Coding and Reporting, Section I.B.16 (Documentation of Complications of Care)Report a problem with this question

11. 11. A category requires a 7th character, but the code built from the Tabular List so far is only five characters long. What must the coder do to produce a valid code?

    • A.Omit the 7th character, because it applies only to codes that are already six characters long.
    • B.Fill the empty character positions with the placeholder X so that the 7th character occupies the seventh position of the data field.✓ Answer
    • C.Attach the 7th character directly after the fifth character so that no positions are left empty.
    • D.Report the five-character code as it stands, since the classification accepts codes of three to seven characters.

    The 7th character carries meaning only because of its position, so it must always sit in the seventh position of the data field. When the code is shorter than six characters, the placeholder X fills the gap; a code that is missing a required placeholder or a required 7th character is invalid, since a code must be reported to the full number of characters required for it.

    Source: ICD-10-CM Official Guidelines for Coding and Reporting, Sections I.A.4 (Placeholder character) and I.A.5 (7th Characters)Report a problem with this question

12. 12. A patient injured several weeks ago is seen today by a physician she has not seen before, who performs further active treatment of the injury. Which 7th character applies, and why?

    • A.'S,' because the injury itself occurred at an earlier date.
    • B.'A' only at the very first visit for an injury; every later visit takes 'D' regardless of what is done.
    • C.'D,' because seeing a different physician makes this a subsequent encounter.
    • D.'A,' because the character reflects whether the patient is receiving active treatment, not which visit it is or which provider is seeing the patient.✓ Answer

    'Initial encounter' is a misleading label: 7th character A is used for each encounter at which the patient is receiving active treatment for the condition, and the guidelines state explicitly that assignment does not depend on the provider seeing the patient for the first time. Character D is reserved for encounters after active treatment has been completed, during routine healing or recovery.

    Source: ICD-10-CM Official Guidelines for Coding and Reporting, Section I.C.19.a (Application of 7th Characters in Chapter 19)Report a problem with this question

13. 13. A patient who has finished active treatment for a fracture returns for routine follow-up during the healing phase. What should be reported as the reason for the encounter?

    • A.The acute injury code with the initial-encounter 7th character, since the fracture has not fully healed.
    • B.An aftercare Z code as the first-listed diagnosis, with the injury code as secondary.
    • C.The acute injury code with the 7th character for subsequent encounter, because aftercare Z codes are not used for aftercare of injuries or poisonings.✓ Answer
    • D.A sequela code, because the acute phase of the fracture has ended.

    Because injury and poisoning categories already carry 7th characters that identify subsequent care, the aftercare Z codes would be redundant and are excluded for these conditions. The healing-phase visit is captured by reporting the acute injury code itself with the subsequent-encounter character; a sequela character would be wrong here because no residual late effect is being treated.

    Source: ICD-10-CM Official Guidelines for Coding and Reporting, Section I.C.19.a (aftercare Z codes not used for injuries) and Section I.C.15.c/I.C.21.c.7 cross-reference on AftercareReport a problem with this question

14. 14. A patient is treated for a scar that formed after a burn sustained two years ago. How is a sequela ordinarily coded?

    • A.The acute-phase code first, followed by the residual condition, to show the full history.
    • B.The sequela (late-effect) code first, followed by the residual condition.
    • C.Only the sequela code, and only if the residual appears within a defined time limit after the acute phase.
    • D.The residual condition first, followed by the sequela code; the code for the acute phase of the original illness or injury is never reported with the late-effect code.✓ Answer

    A sequela is the residual effect remaining after the acute phase has terminated, so the condition actually being treated — the residual — is sequenced first and the code identifying it as a late effect follows. The acute-phase code is never reported alongside the late-effect code because the acute condition no longer exists, and there is no time limit on when a sequela code may be used.

    Source: ICD-10-CM Official Guidelines for Coding and Reporting, Section I.B.10 (Sequela / Late Effects)Report a problem with this question

15. 15. A condition is documented as affecting both the right and the left side, but the classification offers only right and left options with no 'bilateral' code. What should the coder assign?

    • A.The code for whichever side is more severely affected.
    • B.The same unilateral code reported twice on the claim.
    • C.The unspecified-side code, since neither unilateral code alone describes the situation.
    • D.Separate codes for the right side and the left side.✓ Answer

    When laterality is a component of the code but no bilateral option exists, the guidelines direct that separate right and left codes be assigned so that both sides are represented. Reporting one code twice is not an option because each unique diagnosis code may be reported only once per encounter, and the unspecified-side code should be reserved for records that genuinely do not identify the side.

    Source: ICD-10-CM Official Guidelines for Coding and Reporting, Sections I.B.13 (Laterality) and I.B.12 (Reporting Same Diagnosis Code More than Once)Report a problem with this question

16. 16. The Alphabetic Index directs the coder to a single code that classifies a diagnosis together with its associated complication. How should this combination code be handled?

    • A.Report the combination code plus separate codes for each element, so that every component is visible.
    • B.Report the separate individual codes only; combination codes are an optional convenience.
    • C.Combination codes are valid only for inpatient reporting and should be replaced with individual codes in the office setting.
    • D.Report only the combination code when it fully identifies all of the documented elements, adding a secondary code only if the combination code lacks the necessary specificity.✓ Answer

    A combination code exists precisely so that one code classifies two diagnoses, or a diagnosis with its manifestation or complication, and multiple coding is prohibited when the classification already provides a code that clearly identifies all documented elements. The single exception is a combination code that does not fully describe the manifestation or complication, in which case an additional code is added as secondary.

    Source: ICD-10-CM Official Guidelines for Coding and Reporting, Section I.B.9 (Combination Code)Report a problem with this question

17. 17. The provider has definitively diagnosed pneumonia, but the record does not identify the organism or type and no further information is obtainable for this encounter. What is the appropriate code selection?

    • A.Select the specified code that the coder judges to be the most likely type.
    • B.Report no diagnosis code until the type of pneumonia is documented.
    • C.Report a symptom code such as cough or fever instead of a pneumonia code.
    • D.Report the unspecified pneumonia code, because unspecified codes should be used when they most accurately reflect what is known about the condition at that encounter.✓ Answer

    Each encounter is coded to the level of certainty actually known for that encounter, and the guidelines state that unspecified codes have acceptable and even necessary uses. Choosing a specified code that the documentation does not support would misrepresent the record, which is a worse error than reporting the unspecified code the documentation does support.

    Source: ICD-10-CM Official Guidelines for Coding and Reporting, Section I.B.18 (Use of Sign/Symptom/Unspecified Codes) and Section I.B.2 (Level of Detail in Coding)Report a problem with this question

18. 18. In a physician office visit, the assessment reads 'chest pain; rule out gastroesophageal reflux disease.' What should be reported as the first-listed diagnosis?

    • A.Neither; no diagnosis code may be reported when the assessment is inconclusive.
    • B.Gastroesophageal reflux disease, coded as if it had been established.
    • C.Both, with chest pain sequenced first and the reflux disease second.
    • D.Chest pain — the condition is coded to the highest degree of certainty, and 'rule out' conditions are not coded in the outpatient or physician-office setting.✓ Answer

    The guidelines for inconclusive diagnoses were written for inpatient reporting and expressly do not apply to outpatients, so terms such as 'probable,' 'suspected,' 'rule out,' or 'consistent with' are not coded in the office setting. Instead the encounter is coded to the highest degree of certainty available — here the documented symptom — and symptom codes are acceptable precisely because no diagnosis has been confirmed by the provider.

    Source: ICD-10-CM Official Guidelines for Coding and Reporting, Section IV.H (Uncertain diagnosis) and Section IV.D (Codes that describe symptoms and signs)Report a problem with this question

19. 19. A hospital inpatient's discharge summary states 'probable bacterial pneumonia,' and no confirmation was obtained before discharge. How is this coded, and how would identical wording be handled in a physician's office?

    • A.Report no code for the pneumonia in either setting and rely on the procedure codes to explain the stay.
    • B.Code the pneumonia as established in both settings, since the guideline applies to all care settings equally.
    • C.Code the signs and symptoms in both settings, since 'probable' is never sufficient documentation.
    • D.Code it as though the pneumonia existed, because the inpatient uncertain-diagnosis guideline applies; the identical wording in a physician's office would instead be coded to the documented signs and symptoms.✓ Answer

    For inpatient admissions to short-term, acute, long-term care and psychiatric hospitals, a diagnosis qualified at discharge as probable, suspected, likely, questionable, possible or still to be ruled out is coded as if established, because the diagnostic workup and initial therapeutic approach correspond most closely with that diagnosis. The outpatient rule is the deliberate opposite, which is why the same phrase produces two different code sets depending on the setting.

    Source: ICD-10-CM Official Guidelines for Coding and Reporting, Sections II.H and III.C (Uncertain Diagnosis) contrasted with Section IV.HReport a problem with this question

20. 20. The provider documents the same condition as both acute and chronic, and the Alphabetic Index lists separate subentries for 'acute' and 'chronic' at the same indentation level. How should this be coded?

    • A.Code both, sequencing the acute (subacute) code first.✓ Answer
    • B.Code both, sequencing the chronic code first because it was present longer.
    • C.Code only the chronic form, since it represents the patient's ongoing disease.
    • D.Code only the acute form, since it is the more urgent problem.

    The existence of separate subentries at the same indentation level is the classification's own signal that the two forms are distinct and both reportable, so neither may be dropped. The guidelines fix the order, placing the acute or subacute code first, which keeps the sequencing consistent regardless of the coder's view of which form dominated the visit.

    Source: ICD-10-CM Official Guidelines for Coding and Reporting, Section I.B.8 (Acute and Chronic Conditions)Report a problem with this question

21. 21. A patient reports rectal bleeding, and the physician orders a colonoscopy to determine its cause. What should be reported as the reason for the encounter?

    • A.No diagnosis code is needed, because the procedure code already identifies the reason for the test.
    • B.The rectal bleeding, because testing performed to confirm or rule out a suspected diagnosis in a patient who has a sign or symptom is a diagnostic examination, not a screening.✓ Answer
    • C.A screening Z code as the first-listed diagnosis, because a colonoscopy is classified as a screening test.
    • D.A screening Z code first-listed, with the rectal bleeding reported as a secondary diagnosis.

    Screening means testing seemingly well individuals for disease or disease precursors so that early detection is possible; once a sign or symptom prompts the test, the encounter is diagnostic by definition and the sign or symptom is what explains the reason for the test. The same procedure can therefore be either screening or diagnostic depending entirely on why it was ordered.

    Source: ICD-10-CM Official Guidelines for Coding and Reporting, Section I.C.21.c.5 (Screening)Report a problem with this question

22. 22. A nurse's note documents the stage of a pressure ulcer. Which statement reflects the guideline on documentation by clinicians other than the patient's provider?

    • A.Both the ulcer and its stage may be taken from the nurse's documentation, since the nurse assessed the wound directly.
    • B.No documentation from any clinician other than the provider may ever support a code, without exception.
    • C.The stage may be taken from the nurse's documentation, but the pressure ulcer itself must be documented by the patient's provider.✓ Answer
    • D.The stage code may be sequenced as the principal or first-listed diagnosis when it is the most specific information in the record.

    Code assignment rests on documentation by the provider legally accountable for establishing the diagnosis, and only a short, closed list of items — including pressure ulcer stage, BMI, coma scale and laterality — may come from other clinicians. That exception covers the descriptive detail only: the associated diagnosis, here the pressure ulcer, still requires provider documentation, and conflicting documentation calls for a query.

    Source: ICD-10-CM Official Guidelines for Coding and Reporting, Section I.B.14 (Documentation by Clinicians Other than the Patient's Provider)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 →