Free AHIMA CCS Practice Test: 49 Questions

Answer: A. Code the flank pain only

For outpatient encounters, don't code diagnoses documented as probable, suspected, questionable or rule out. Code the condition to the highest degree of certainty for that visit, which here is the symptom. The guideline itself notes this differs from inpatient hospital practice.

• B: That is the inpatient rule for uncertain diagnoses at discharge. It does not apply to outpatient encounters, including ED visits.
• C: An outpatient diagnosis qualified as probable is not coded at all, so it can't be added alongside the symptom.
• D: The encounter is reportable now. You code what is certain for this visit, not what a later visit might confirm.

Source: 2026 ICD-10-CM Official Guidelines, Section IV.H

Answer: C. Major complication or comorbidity (MCC)

CMS's FY2026 MS-DRG CC/MCC list designates J96.01 as an MCC. That status can be suppressed only by a CC exclusion tied to the principal diagnosis, which the stem rules out. The designation matters only when the diagnosis is documented and reportable; it never justifies adding a diagnosis.

• A: J96.01 is listed at the higher MCC level, not the CC level.
• B: J96.01 carries a severity designation on the CMS list; it isn't a non-CC code.
• D: Severity level comes from the CMS CC/MCC list for the code, not from the intensity of treatment the coder observes.

Source: CMS, FY2026 MS-DRG v43.1 CC/MCC list (Appendix C), Part 1, row J9601; CMS, FY2026 MS-DRG v43.1 CC exclusion collection 0998, Exclusion collection for J9601

Answer: D. Either condition may be sequenced as the principal diagnosis

When two or more diagnoses equally meet the criteria for principal diagnosis, as shown by the circumstances of admission, the diagnostic workup and/or the therapy provided, and neither the Index, Tabular nor other guidelines direct sequencing, any one of them may be sequenced first.

• A: Severity is not the test for principal diagnosis. When two diagnoses equally meet the definition, the guideline allows either.
• B: The order of entries in the H&P doesn't determine the principal diagnosis.
• C: Both diagnoses are established. Symptom codes are not a tiebreaker for two confirmed conditions.

Source: 2026 ICD-10-CM Official Guidelines, Section II.C

Answer: B. The NSTEMI that led to the admission

When a patient in observation for a medical condition worsens or doesn't improve and is then admitted, the principal diagnosis is the medical condition that led to the hospital admission.

• A: The reason for observation doesn't carry over when the condition worsens or doesn't improve and leads to admission. The chest pain is also a symptom of the established diagnosis.
• C: The patient became an inpatient. The principal diagnosis is the condition that led to the admission.
• D: Payment never determines the principal diagnosis.

Source: 2026 ICD-10-CM Official Guidelines, Section II.I.1; Section I.B.5

Answer: B. The complication

For an admission from outpatient surgery: if the reason for the inpatient admission is a complication, the complication is the principal diagnosis. If nothing else is documented as the reason, use the reason for the outpatient surgery. If an unrelated condition is the reason, that condition is principal.

• A: That applies only when no complication or other condition is documented as the reason for the inpatient admission.
• C: An unrelated condition is principal only when it is the documented reason for the admission.
• D: Aftercare codes don't describe an admission for an acute postoperative complication.

Source: 2026 ICD-10-CM Official Guidelines, Section II.J

Answer: D. Y

Assign Y to conditions diagnosed during the admission that were clearly present but not diagnosed until after admission occurred.

• A: The test is whether the condition was present when the inpatient order occurred, not when it was diagnosed.
• B: U means documentation is insufficient. Here the provider has documented that the tumor was present before admission.
• C: W means the provider is clinically unable to determine POA status. This provider made a determination.

Source: 2026 ICD-10-CM Official Guidelines, Appendix I, Present on Admission Reporting Guidelines

Answer: A. Y, because it occurred before the inpatient order

Present on admission means present at the time the order for inpatient admission occurs. Conditions that develop during an outpatient encounter, including the emergency department, observation or outpatient surgery, are considered present on admission.

• B: Location isn't the test. POA is measured against the time the inpatient admission order occurs.
• C: The timing is documented: the fracture occurred before the inpatient order.
• D: A blank POA field is allowed only for codes on the POA exempt list.

Source: 2026 ICD-10-CM Official Guidelines, Appendix I, General reporting requirements

Answer: C. Open

Procedures performed using the open approach with percutaneous endoscopic assistance are coded to the approach Open. The PCS guidelines use a laparoscopic-assisted sigmoidectomy as their example.

• A: This report expressly describes an open approach with percutaneous endoscopic assistance. B5.2b separately addresses procedures performed percutaneous endoscopically with hand assistance or an incision used for specimen removal or anastomosis.
• B: Percutaneous means entry by puncture or minor incision without an endoscope, which doesn't describe this procedure.
• D: That approach describes entry through a natural opening such as the anus or mouth, as in colonoscopy.

Source: 2026 ICD-10-PCS Official Guidelines, Guidelines B5.2a and B5.2b

Answer: C. Resection of the sigmoid colon; the anastomosis is not coded separately

Resection is coded whenever all of a specific body part is cut out or off. Procedural steps needed to reach and close the operative site, including the anastomosis in a sigmoid colon resection, are not coded separately.

• A: Excision is for removing a portion of a body part, and the anastomosis isn't coded on its own.
• B: The anastomosis is the step that restores continuity after the resection. It is not a separate Bypass procedure here.
• D: The sigmoid colon is its own PCS body part, and all of it was removed, so the root operation is Resection of that body part.

Source: 2026 ICD-10-PCS Official Guidelines, Guidelines B3.8 and B3.1b

Answer: A. Code both the diagnostic biopsy and the partial hepatectomy

If a diagnostic Excision, Extraction or Drainage (biopsy) is followed by a more definitive procedure at the same procedure site, both the biopsy and the more definitive treatment are coded.

• B: When a diagnostic biopsy is followed by more definitive treatment at the same site, both are coded.
• C: The definitive procedure must be coded; it is the main procedure of the episode.
• D: A biopsy takes the diagnostic qualifier X. Qualifier Z (no qualifier) would drop the diagnostic designation.

Source: 2026 ICD-10-PCS Official Guidelines, Guidelines B3.4a and B3.4b

Answer: B. Only the stent placement

Inspection of a body part performed in order to achieve the objective of a procedure is not coded separately. Only the stent placement is reported.

• A: Inspection performed to achieve the objective of the procedure is not coded separately.
• C: That leaves out the procedure that was actually performed.
• D: The most-distal rule tells you which body part to use when an inspection is coded. Here the inspection isn't coded at all.

Source: 2026 ICD-10-PCS Official Guidelines, Guidelines B3.11a and B3.11b

Answer: D. None of them

Signs and symptoms that are routinely associated with a disease process should not be assigned as additional codes unless the classification instructs otherwise.

• A: Localized abdominal pain is a routine feature of appendicitis and is not coded separately.
• B: Signs and symptoms routinely associated with a disease process are not assigned as additional codes.
• C: Low-grade fever is attributed to the appendicitis and is part of its usual presentation.

Source: 2026 ICD-10-CM Official Guidelines, Section I.B.5; NIDDK, Symptoms & Causes of Appendicitis, Symptoms; last reviewed July 2021

Answer: D. It's denied unless a supported PTP-associated modifier is reported

PTP edits pair a column one code with a column two code. When both are reported for the same beneficiary on the same date, the column two code is denied unless a clinically appropriate PTP-associated modifier is reported, and the documentation must support that modifier. If the edit's modifier indicator is 0, no modifier bypasses it.

• A: CMS publishes separate PTP edit files for hospitals and for practitioners. Hospital outpatient claims are not exempt.
• B: That describes a multiple-procedure reduction, not a PTP edit.
• C: PTP edits act on code pairs on the same claim; they don't move services between claims.

Source: CMS, Medicare NCCI Procedure-to-Procedure (PTP) Edits, Overview of PTP edits; Hospital PTP Edits files; CMS, Medicare NCCI FAQ Library, Procedure-to-Procedure (PTP) Edits, question 10: modifier indicators

Answer: B. XS

XS identifies a service that is distinct because it was performed on a separate organ or structure. CMS says to use modifier 59 only if no more descriptive modifier is available, and never to bypass an edit unless the modifier's criteria are met.

• A: Modifier 59 is used only when no more descriptive modifier is available. XS describes this situation more precisely.
• C: XE is for a separate encounter on the same date. These procedures were in the same encounter.
• D: XU is for an unusual non-overlapping service. The distinguishing fact here is a separate organ or structure.

Source: CMS MLN1783722, Proper Use of Modifiers 59, XE, XP, XS & XU (April 2026), pp. 3–4: definitions of XE, XP, XS, XU; use of modifier 59 and anatomic modifiers

Answer: C. The maximum units of a code expected on the vast majority of appropriate claims for one patient, provider and date

An MUE is the maximum units of service reported for a HCPCS/CPT code on the vast majority of appropriately reported claims by the same provider or supplier for the same beneficiary on the same date of service. Not every code has an MUE.

• A: Medical necessity is addressed through coverage policies such as NCDs and LCDs, not MUEs.
• B: That is a procedure-to-procedure (PTP) edit.
• D: MUEs measure units per code per date of service, not visits per year.

Source: CMS, Medicare NCCI Medically Unlikely Edits, MUE definition

Answer: A. They're packaged into the payment for the J1 procedure

Services with status indicator J1 are assigned to comprehensive APCs (C-APCs). Adjunctive services reported on the same claim are generally packaged into the payment for the primary J1 service. CMS lists specific services that are excluded from C-APC packaging.

• B: J1 procedures are assigned to comprehensive APCs, which package adjunctive services on the claim into one payment.
• C: The adjunctive services in this OPPS claim are generally packaged into the primary J1 payment, rather than paid separately under the Physician Fee Schedule.
• D: Packaged services are reported and included in the payment. They are not denied as errors.

Source: CMS Medicare Claims Processing Manual, Chapter 4, Sections 10.2.3 and 10.4, comprehensive APCs and packaging exceptions; Section 10.1, services outside OPPS

Answer: B. Query the patient's provider to clarify the conflicting documentation

Laterality is one of the details that may be taken from documentation by clinicians other than the patient's provider. When documentation conflicts, whether from the same clinician or different clinicians, the patient's provider should be queried for clarification.

• A: Laterality may be taken from other clinicians' documentation, which is exactly why a conflict between them must be clarified rather than picked.
• C: Other clinicians' documentation is acceptable for laterality only when it doesn't conflict.
• D: Unspecified laterality hides a documentation conflict that should be resolved.

Source: 2026 ICD-10-CM Official Guidelines, Sections I.B.13 and I.B.14

Answer: D. Don't code it from the nursing note; query the provider

Pressure ulcer stage may be based on documentation from clinicians other than the patient's provider, but the associated diagnosis must be documented by the patient's provider. With no provider diagnosis, the right step is a query.

• A: The stage may come from the wound nurse, but the pressure ulcer diagnosis itself must be documented by the patient's provider.
• B: Without a provider diagnosis, no pressure ulcer code is supported at any stage.
• C: That substitutes a different diagnosis that no one documented.

Source: 2026 ICD-10-CM Official Guidelines, Section I.B.14

Answer: C. Yes; the NP counts as a provider under the guidelines

Throughout the ICD-10-CM guidelines, provider means a physician or any qualified health care practitioner who is legally accountable for establishing the patient's diagnosis. If the NP's diagnosis conflicted with the attending's documentation, a query would be the next step.

• A: The guidelines define provider broadly, not as the attending physician only.
• B: The guidelines don't make cosignature the test for whether a qualified practitioner's diagnosis can be coded.
• D: Coders don't establish diagnoses from lab values, and code assignment is based on the provider's diagnostic statement.

Source: 2026 ICD-10-CM Official Guidelines, Introduction (definition of provider); Section I.B.14

Answer: A. Code the pneumonia only

For outpatient encounters for diagnostic tests interpreted by a physician, when the final report is available at the time of coding, code any confirmed or definitive diagnosis documented in the interpretation. Don't code related signs and symptoms as additional diagnoses. The guideline notes this differs from inpatient practice for abnormal findings.

• B: For outpatient diagnostic tests interpreted by a physician, the confirmed diagnosis in the final interpretation is coded.
• C: Related signs and symptoms are not coded as additional diagnoses once a definitive diagnosis is confirmed.
• D: Z01.89 is for routine testing with no signs, symptoms or associated diagnosis. This test was ordered for a symptom.

Source: 2026 ICD-10-CM Official Guidelines, Section IV.K

Answer: A. Don't code it from the report alone; query if it seems significant

For inpatients, abnormal findings (laboratory, x-ray, pathology and other diagnostic results) are not coded and reported unless the provider indicates their clinical significance. A query is appropriate when a finding appears significant but the provider hasn't addressed it.

• B: Inpatient abnormal findings are coded only when the provider indicates their clinical significance. The outpatient interpreted-test rule doesn't apply to inpatients.
• C: An abnormal-findings code also needs the provider to indicate clinical significance.
• D: POA indicators don't decide whether a condition is reportable.

Source: 2026 ICD-10-CM Official Guidelines, Section III.B; Section IV.K (note on inpatient difference)

Answer: C. Resolve the conflict under facility policy before final abstraction

Medicare's post-acute care transfer policy can reduce payment for qualifying MS-DRGs when the stay is shorter than the geometric mean and the patient goes to a post-acute setting such as a SNF. Discharge status is also a grouper input for some MS-DRGs. Conflicting documentation of where the patient went must be resolved before abstraction is final.

• A: Discharge status is abstracted data, and conflicting documentation should be resolved rather than defaulted to one note.
• B: Discharge status is a required grouping and claims data element.
• D: Choosing data to maximize payment is a compliance problem, not a resolution.

Source: 42 CFR 412.4, Discharges and transfers, Paragraphs (c) and (f); CMS, MS-DRG Classifications and Software, MS-DRG inputs

Answer: D. Query the provider

Assign the POA indicator using the applicable guidelines and supporting documentation. When documentation is unclear at the time of code assignment, it is appropriate to query the provider. Indicator U applies when documentation remains insufficient to determine POA status.

• A: First documentation after admission doesn't establish that the condition developed after admission.
• B: Coders don't make clinical judgments about POA status.
• C: A blank POA field is allowed only for codes on the exempt list.

Source: 2026 ICD-10-CM Official Guidelines, Appendix I, Assigning the POA indicator

Answer: B. Don't code it as current; add a history code if it affects care

Code all documented conditions that coexist at the time of the encounter and affect care. Don't code conditions that were previously treated and no longer exist. History codes may be used as secondary codes if the historical condition has an impact on current care or influences treatment.

• A: Conditions that were previously treated and no longer exist are not coded as current.
• C: The reason for this visit is the hypertension follow-up.
• D: History codes may be used as secondary codes when the history affects current care or influences treatment.

Source: 2026 ICD-10-CM Official Guidelines, Section IV.J

Answer: D. A POA query on a documented pressure ulcer offering yes, no or unable to determine

Yes/no queries may be used to determine POA status (inpatient only) and to establish or negate a cause-and-effect relationship between documented conditions. They may not introduce a new diagnosis, and POA yes/no queries must include an unable-to-determine option.

• A: A yes/no query may not be used to introduce a new, previously undocumented diagnosis.
• B: Queries must never include reimbursement or quality impact, and this introduces a new diagnosis.
• C: POA yes/no queries require an option that lets the provider indicate an inability to determine.

Source: ACDIS/AHIMA, Guidelines for Achieving a Compliant Query Practice (2026 Update), Definitions (p. 5); Section V.II.B (pp. 12–13); Section V.I.B (p. 7)

Answer: B. It needs at least one supported, clinically valid option and a way to answer otherwise

Only clinically relevant options belong on a multiple-choice query. There is no minimum number, but every query must include at least one clinically valid option supported by the health record and must allow the provider to offer an alternative explanation or diagnosis.

• A: There is no required minimum number of answer choices.
• C: Only clinically relevant options should be included.
• D: Queries must never include reimbursement or quality impact.

Source: ACDIS/AHIMA, Guidelines for Achieving a Compliant Query Practice (2026 Update), Section V.II.A (pp. 10–11); Section V.I.B (p. 7)

Answer: A. After the provider documents the response in the health record

A response to a verbal query must be documented in the permanent health record to be coded. The verbal query itself should be recorded with the date and time, participants, clinical indicators and their sources, the question, any options and the provider's response.

• B: The CDI specialist's note is not provider documentation of the diagnosis.
• C: The requirement is documentation in the health record, not who heard the answer.
• D: Verbal queries are allowed when they are properly recorded and the response is documented.

Source: ACDIS/AHIMA, Guidelines for Achieving a Compliant Query Practice (2026 Update), Section V.III (p. 15)

Answer: C. Send the attending a nonleading query with the clinical indicators

Queries are appropriate when documentation is incomplete or does not reflect the clinical picture. The guideline that lets coders use other clinicians' documentation covers only listed details such as BMI, not a malnutrition diagnosis, so the provider must be asked.

• A: Malnutrition is a diagnosis, and diagnoses must be documented by the patient's provider.
• B: A BMI code requires an associated reportable diagnosis documented by the provider, and closing the record skips a clear query opportunity.
• D: Only the patient's provider can establish the diagnosis for coding.

Source: ACDIS/AHIMA, Guidelines for Achieving a Compliant Query Practice (2026 Update), Section VI (p. 17); 2026 ICD-10-CM Official Guidelines, Section I.B.14 (pp. 15–16)

Answer: C. Refuse, because the record doesn't support the change

AHIMA's standards direct coders to refuse to participate in, support or change reported data that misrepresents the patient's condition, and the guidance under Standard 5 warns against changes made to inappropriately increase reimbursement, including changing unsupported codes at a business office's request.

• A: Approval from the business office doesn't make unsupported data accurate.
• B: Documenting the request doesn't cure the inaccurate claim.
• D: A query needs clinical indicators and must never mention reimbursement.

Source: AHIMA Standards of Ethical Coding (2016 version, current), Standards 3 and 5; Guideline 5.3

Answer: A. Report it through formal channels, such as the compliance hotline

The standards direct coders to refuse to participate in or conceal unethical coding, data abstraction or query practices, and to escalate concerns through the organization's formal channels.

• B: Silently fixing records conceals the pattern instead of reporting it.
• C: The standards direct coders not to conceal unethical coding.
• D: A public forum bypasses the organization’s reporting process; sharing identifiable case details could also breach confidentiality.

Source: AHIMA Standards of Ethical Coding (2016 version, current), Standard 11

Answer: D. PSIs are AHRQ quality measures; HACs are a CMS payment provision

AHRQ developed the PSIs as quality measures that use hospitals' administrative data to flag potentially preventable complications. The HAC provision, from the Deficit Reduction Act of 2005, stops IPPS hospitals from receiving additional payment for selected conditions that were not present on admission.

• A: PSIs are quality measures developed by AHRQ, not claim-level payment rules.
• B: PSIs are built from hospital administrative data, which is why coding accuracy and POA indicators matter.
• C: The ownership is reversed.

Source: AHRQ PSNet, Patient Safety Indicators Overview, Overview; CMS, Hospital-Acquired Conditions (HAC), Background and HAC categories

Answer: B. It's coded, and the case is paid as if it weren't present

Catheter-associated UTI is a CMS HAC category. When a selected HAC was not present on admission, the hospital receives no additional payment for it, and the case is paid as though the secondary diagnosis were not present. The condition is still coded accurately.

• A: Omitting this reportable condition to affect payment makes the claim inaccurate.
• C: The HAC provision removes the condition's effect on payment; it doesn't deny the stay.
• D: The condition developed after admission, so the indicator is N.

Source: CMS, Hospital-Acquired Conditions (HAC), HAC categories; payment when not POA

Answer: A. ICD-10-PCS for inpatient hospital facility procedures; CPT/HCPCS for physician and hospital outpatient services

Under 45 CFR 162.1002, ICD-10-CM is the standard for diseases and conditions, ICD-10-PCS for procedures on hospital inpatients reported by hospitals, and HCPCS with CPT for physician services and other health care services (CDT covers dental services).

• B: Hospitals report inpatient procedures with ICD-10-PCS.
• C: ICD-10-PCS is the standard for inpatient hospital procedures only.
• D: ICD-10-CM is the standard for diagnoses and conditions, not procedures.

Source: 45 CFR 162.1002, Medical data code sets, Paragraphs (a)(4)–(5) and (c)

Answer: B. Give it before the service; with a valid ABN the patient may be liable

Providers must notify a beneficiary in advance when they believe Medicare will likely deny an item or service as not reasonable and necessary. A beneficiary who receives a properly written and delivered ABN and agrees to pay may be held liable; without required notice, liability generally shifts to the provider.

• A: The notice must be given before the item or service is furnished.
• C: ABNs are not required for statutorily excluded care, though a voluntary notice may be given.
• D: Without required proper notice, the beneficiary generally isn't liable and the provider bears the cost.

Source: CMS Medicare Claims Processing Manual, Chapter 30, Section 50 (ABN), Sections 50.1, 50.2, 50.2.1, 50.8 and 50.9 (PDF pp. 37–38, 45, 47)

Answer: D. Provider-documented depression, with the home antidepressant continued

Other diagnoses are conditions that coexist at admission or develop later and affect patient care through clinical evaluation, therapeutic treatment, diagnostic procedures, extended length of stay or increased nursing care or monitoring. Continuing the antidepressant is therapeutic treatment.

• A: Conditions from an earlier episode that have no bearing on the current stay are excluded.
• B: Abnormal findings aren't coded unless the provider indicates their clinical significance.
• C: A ruled-out diagnosis is not coded as if it existed.

Source: 2026 ICD-10-CM Official Guidelines, Section III and III.B

Answer: C. Only when the code is on the POA exempt list

Leave the POA field blank only if the condition is on the list of ICD-10-CM codes for which POA reporting does not apply. The guidelines describe this as the only circumstance in which the field may be left blank.

• A: Uncertainty is resolved by querying the provider, and indicator U covers insufficient documentation.
• B: POA indicators are required for principal and secondary diagnoses unless the code is exempt.
• D: Payment impact doesn't determine whether a POA indicator is reported.

Source: 2026 ICD-10-CM Official Guidelines, Appendix I

Answer: D. It assigns the MS-DRG from the codes and patient data reported

CMS classifies inpatient cases into MS-DRGs from the principal diagnosis, up to 24 additional diagnoses and up to 25 procedures. In a small number of MS-DRGs, age, sex and discharge status also matter. A grouper applies that logic to the codes you assign, which is why coding errors flow straight into the DRG.

• A: That describes computer-assisted coding (CAC), not a grouper.
• B: Record storage is a function of the EHR, not the grouper.
• C: Medical necessity is determined under coverage policies, not by the grouper.

Source: CMS, MS-DRG Classifications and Software, MS-DRG definitions and grouper software

Answer: C. Validate it against provider documentation and the guidelines

AHIMA's ethical coding standards state that computer-assisted coding and electronic encoders are only tools and do not replace the coder's professional judgment. Here the diagnosis also lacks provider documentation, so it can't be coded as suggested.

• A: CAC and encoders are tools; they don't replace the coder's judgment or the documentation requirements.
• B: A confidence score doesn't turn a nursing phrase into a provider diagnosis.
• D: CAC output is useful when it is reviewed; the problem is accepting it without validation.

Source: AHIMA Standards of Ethical Coding (2016 version, current), Standard 9; 2026 ICD-10-CM Official Guidelines, Section I.B.14

Answer: B. A hybrid health record

A health record may be paper, electronic, or both; a record kept partly on paper and partly in electronic systems is called a hybrid record. Coders working in hybrid environments have to know where each part of the record lives before deciding documentation is missing.

• A: Part of the record is still on paper, so it isn't fully electronic.
• C: A personal health record is maintained by the patient, not the hospital.
• D: The clinical documentation itself is electronic here, not just an index.

Source: Indian Health Manual, Part 3, Chapter 3 (Health Information Management), Section 3-3.2B(1)

Answer: A. Notify the individuals, the media and HHS without unreasonable delay and within the applicable 60-day limit

Individuals must be notified without unreasonable delay and no later than 60 days after discovery. A breach involving more than 500 residents of a state or jurisdiction also requires notice to prominent media outlets without unreasonable delay and within 60 days, and breaches of 500 or more must be reported to the HHS Secretary contemporaneously with the individual notice.

• B: The individual notice deadline is 60 days, and a breach of more than 500 residents of a state also requires media notice.
• C: The annual log option is for breaches affecting fewer than 500 individuals.
• D: Individual notice is required here; media notice does not replace it.

Source: 45 CFR 164.404, Notification to individuals, Paragraph (b); 45 CFR 164.406, Notification to the media, Paragraphs (a) and (b); 45 CFR 164.408, Notification to the Secretary, Paragraph (b); 45 CFR 164.412, Law enforcement delay, Exception excluded by the stem; HHS, Breach Notification Rule, Individual, media and Secretary notice

Answer: B. J18.9 (POA Y), A41.9 (POA N)

The pneumonia occasioned the admission and the sepsis developed afterward, so the localized infection (J18.9) is sequenced first, followed by the sepsis code (A41.9). The attending documents that the sepsis was not present when the inpatient order was written, so its POA indicator is N.

• A: This incorrectly marks the sepsis present on admission and places it before the pneumonia that occasioned admission.
• C: The POA indicators are correct, but pneumonia is sequenced first in this case because sepsis developed after admission.
• D: R65.20 is severe sepsis and needs documented acute organ dysfunction; the record says none was documented.

Source: 2026 ICD-10-CM Official Guidelines, Section I.C.1.d.4; Appendix I; CMS, 2026 ICD-10-CM Tabular List and Index (ZIP), J18.9, A41.9, R65.20

Answer: B and D. B. E11.65; D. Z79.4

The attending documents type 2 diabetes with hyperglycemia (E11.65), and the patient uses insulin only, so the E11 use-additional-code note calls for Z79.4. Sequence E11.65 before Z79.4.

• A: E11.9 is diabetes without complications; hyperglycemia is documented and treated.
• C: Z79.84 is for oral hypoglycemic drugs; this patient takes insulin only.

Source: 2026 ICD-10-CM Official Guidelines, Section I.C.4.a.3; CMS, 2026 ICD-10-CM Tabular List and Index (ZIP), E11.65, E11.9, Z79.4, Z79.84 and the E11 use-additional-code note

Answer: C. 02HV33Z

02HV33Z is Insertion of Infusion Device into Superior Vena Cava, Percutaneous Approach. The body part comes from where the catheter tip ends up, the superior vena cava, not from the vein used for access.

• A: 05HB33Z reports an infusion device in the right basilic vein, the access vessel, not the tip location.
• B: 02HV03Z uses the Open approach; the PICC was placed percutaneously.
• D: The access vein isn't reported separately; one code describes the device and where it ends.

Source: CMS, 2026 ICD-10-PCS tables and index (ZIP), Tables 02H and 05H; 02HV33Z, 02HV03Z, 05HB33Z; CMS, ICD-10-PCS Reference Manual (2016), p. 67, Insertion example 4: central infusion-device tip in the superior vena cava; code values checked in the 2026 tables

Answer: C. K80.10

For ambulatory surgery, when the postoperative diagnosis differs from the preoperative diagnosis and is confirmed, code the postoperative diagnosis because it is the most definitive. Chronic calculous cholecystitis without obstruction is K80.10.

• A: K80.20 is calculus of the gallbladder without cholecystitis, the preoperative impression that the findings replaced.
• B: K80.00 is for acute cholecystitis; the surgeon and pathology document chronic cholecystitis.
• D: The preoperative diagnosis isn't reported alongside the more definitive postoperative diagnosis.

Source: 2026 ICD-10-CM Official Guidelines, Sections IV.N and IV.K; CMS, 2026 ICD-10-CM Tabular List and Index (ZIP), K80.00, K80.10, K80.20

Answer: A. E11.9 and Z79.84

The H&P documents type 2 diabetes without complications (E11.9) managed with metformin, an oral hypoglycemic drug, so the E11 use-additional-code note calls for Z79.84 after E11.9.

• B: Z79.4 is for insulin; this patient takes metformin.
• C: E11.65 requires documented hyperglycemia, which isn't in this record.
• D: The E11 note directs you to add the code for the drug used to control the diabetes.

Source: 2026 ICD-10-CM Official Guidelines, Sections I.C.4.a.3 and IV.J; CMS, 2026 ICD-10-CM Tabular List and Index (ZIP), E11.9, E11.65, Z79.4, Z79.84

Answer: A and D. A. Report CPT 47562 for the laparoscopic cholecystectomy; D. Hospital outpatient procedures are reported with CPT/HCPCS, not ICD-10-PCS

HIPAA code set rules assign ICD-10-PCS to procedures on hospital inpatients; hospital outpatient services use HCPCS/CPT. A laparoscopic cholecystectomy without intraoperative cholangiography is CPT 47562.

• B: 0FT44ZZ describes the same operation in ICD-10-PCS, but PCS is the standard for inpatient hospital procedures, not outpatient surgery.
• C: 47563 includes intraoperative cholangiography, which wasn't performed; preoperative imaging doesn't change the code.

Source: 45 CFR 162.1002, Medical data code sets, Paragraphs (a)(5) and (c); Massachusetts EOHHS, FASC Service Codes Spreadsheet (effective May 1, 2026), p. 101, code descriptions for 47562 and 47563; American College of Surgeons, Physicians as Assistants at Surgery: 2023 Update, p. 137 (PDF p. 140), code descriptions for 47562 and 47563; CMS, 2026 ICD-10-PCS tables and index (ZIP), Table 0FT; 0FT44ZZ (inpatient code, not used for this outpatient claim)

Answer: B. R07.9

"Likely" GERD is an uncertain diagnosis, and uncertain diagnoses are not coded for outpatient encounters, including ED visits. Code to the highest degree of certainty: the chest pain, documented without further description (R07.9, chest pain, unspecified).

• A: K21.9 is GERD without esophagitis, which is documented only as likely.
• C: R07.89 is other chest pain, such as atypical or chest-wall pain; this record says only "chest pain."
• D: The uncertain GERD diagnosis can't be added as a secondary code either.

Source: 2026 ICD-10-CM Official Guidelines, Section IV.H; CMS, 2026 ICD-10-CM Tabular List and Index (ZIP), R07.9, R07.89, K21.9

Answer: A and C. A. I10; C. F17.210

Essential hypertension on amlodipine (I10) is a chronic condition under treatment, and the physician documents nicotine dependence, cigarettes (F17.210, uncomplicated).

• B: Z72.0 is tobacco use; it carries an Excludes1 note for nicotine dependence (F17.2-), which is documented here.
• D: Z87.891 is history of nicotine dependence; this patient currently smokes.

Source: 2026 ICD-10-CM Official Guidelines, Sections IV.I and IV.J; CMS, 2026 ICD-10-CM Tabular List and Index (ZIP), I10, F17.210, Z72.0, Z87.891

Answer: B. 99284

Facility visit levels come from the hospital's own criteria, which must reasonably relate the intensity of hospital resources to the visit levels. This hospital's criteria place the visit at Level 4, which it maps to 99284. The physician's professional level is a separate claim.

• A: The physician's MDM supports the professional E/M level, not the facility level.
• C: Level 3 doesn't match the hospital's criteria for cardiac monitoring plus three or more tests.
• D: Diagnostic tests are reported in addition to the facility visit, not instead of it.

Source: CMS Medicare Claims Processing Manual, Chapter 4, Section 160 (PDF p. 149), Clinic and Emergency Visits: hospital criteria and Type A/Type B ED code sets; CMS, CY2026 OPPS Final Rule Claims Accounting, p. 33: 99281–99285 map to ED visit levels 1–5