Free CCDS-O Practice Test Questions 2026

Explanation:
The problem list contains conflicting or outdated information—both "DM 2 associated erectile dysfunction" and "DM 2 without complications"—while the most recent clinic note states "DM 2 with autonomic neuropathy" was addressed. This indicates ambiguity about the patient's current diabetic status and complications. The first step for the CDI specialist is to clarify the correct diagnosis through a compliant query before the upcoming visit, ensuring accurate and consistent documentation.

Correct Option:

B. Query if the DM 2 is with or without complications
This is correct. The presence of conflicting diagnoses (DM with erectile dysfunction, DM without complications, and DM with autonomic neuropathy) creates significant ambiguity. The CDI specialist should query the provider to clarify the correct, current diabetes diagnosis and its associated complications before the upcoming visit. This ensures the problem list and clinical documentation are accurate, consistent, and reflect the patient's true health status for risk adjustment and continuity of care.

Incorrect Options:

A. Remove DM 2 without complications from the problem list
This is incorrect. CDI specialists do not have the authority to independently modify the problem list. Only the treating provider can add, remove, or update diagnoses on the problem list. Additionally, removing a diagnosis without provider clarification could result in loss of important clinical information.

C. Ask the patient if he still has DM 2 with autonomic neuropathy
This is incorrect. Patients are not qualified to provide diagnostic information. The CDI specialist must rely on provider documentation and clinical indicators. Asking the patient about specific diagnoses is outside the CDI scope and could lead to inaccurate or misinterpreted information.

D. Query the provider for the link between erectile dysfunction and DM 2
This is incorrect. While erectile dysfunction can be a complication of diabetes, the most pressing ambiguity is the conflict between "DM without complications" and "DM with autonomic neuropathy" in the most recent note. Querying only about erectile dysfunction does not resolve the primary documentation discrepancy and may miss the more significant complication.

Reference:

ACDIS/AHIMA "Guidelines for Achieving a Compliant Query Practice" – Queries should clarify ambiguous, conflicting, or incomplete documentation.

ICD-10-CM Official Guidelines – Diabetes with complications (E11.4-, E11.6-, etc.) must be documented by the provider; conflicting diagnoses require clarification.

AHIMA "Managing the Problem List" – The problem list should be accurate and current; conflicting entries should be resolved by the provider.

CDI best practices – The first step in resolving documentation conflicts is to query the provider for clarification, not to make independent changes.

Explanation:
The majority of Evaluation and Management (E/M) services are categorized and selected based on a framework that first determines the correct category of service. This framework is defined by the patient's status (new or established), the place of service (where the encounter takes place), and the level of service (determined by medical decision-making or total time).

Correct Option:

A. New/established, site of service, and level of service
This is correct. The fundamental classification of E/M services uses patient status, place of service, and type/service level to select the appropriate code range. The "site of service" is a primary differentiator (e.g., office, hospital, emergency department). Within a category, the "level of service" is then determined by Medical Decision Making (MDM) or total time.

Incorrect Options:

B. New/established, site of service, and time
This is incorrect. While time is one of the two key methods for selecting the specific level of service, it is not a primary criterion for placing a service into a general category. The classification of the service type (e.g., office visit vs. hospital care) is determined first.

C. New/established, physician specialty, and level of service
This is incorrect. Physician specialty is not a factor in selecting a base E/M category. However, it is critical for applying the 3-year rule to determine the "new/established" patient status, as a patient seen by a physician of a different specialty in the same group may still be considered "new".

D. New/established, level of service, and age of patient
This is incorrect. The patient's age is not a primary element for classifying or leveling E/M services. The primary differentiation is between new and established patients; the level of service is subsequently determined by MDM or time, and the "site of service" is the other major classification factor.

Reference:
CPT guidelines and Medicare manuals categorize E/M services by place of service, patient status (new/established), and type of service. The level is then determined by Medical Decision Making (MDM) or total time.

Explanation:
In ICD-10-CM coding, diagnoses documented as "uncertain," "possible," "probable," "suspected," or "rule out" are treated differently in inpatient vs. outpatient settings. In the outpatient setting, uncertain diagnoses are not coded; only confirmed diagnoses are reported. Among the options, "concern for" clearly indicates diagnostic uncertainty, making it an uncertain diagnosis that would not be coded in an outpatient encounter.

Correct Option:

A. Concern for streptococcal pneumonia
This is correct. The phrase "concern for" indicates that the diagnosis is suspected but not confirmed. In the outpatient setting, ICD-10-CM guidelines prohibit coding uncertain diagnoses. The provider is expressing a clinical suspicion, but without definitive confirmation, the condition should not be coded.

Incorrect Options:

B. Treating a streptococcal pneumonia with antibiotic
This is incorrect. The documentation explicitly states "treating a streptococcal pneumonia," which indicates the provider has confirmed the diagnosis and is actively managing it with antibiotics. This is a confirmed diagnosis and can be coded.

C. Evidence of streptococcal pneumonia
This is incorrect. While "evidence of" may suggest supporting findings, in this context it implies that the diagnosis is supported by clinical indicators and is being treated as a confirmed condition. It does not carry the same uncertainty as "concern for" and is considered a confirmed diagnosis for coding purposes.

D. Broad spectrum antibiotic prescribed for streptococcal pneumonia
This is incorrect. The documentation clearly states "streptococcal pneumonia" as the condition being treated. The prescription of a broad-spectrum antibiotic further supports that the diagnosis is confirmed and being actively managed. This is a confirmed diagnosis and should be coded.

Reference:

ICD-10-CM Official Guidelines for Coding and Reporting – Section I.B.3 – In the outpatient setting, do not code diagnoses documented as "probable," "suspected," "questionable," "rule out," or "working diagnosis." Code the condition(s) to the highest degree of certainty.

ICD-10-CM Guidelines – Inpatient vs. outpatient coding rules for uncertain diagnoses differ; outpatient coding requires confirmed diagnoses only.

AHA Coding Clinic – Guidance on coding "concern for" and "suspected" conditions in outpatient settings.

Explanation:
A compliant query is appropriate when there is a clinical discrepancy, an ambiguous relationship, or a need to clarify a diagnosis that is not supported by the documented treatment. While many treatments have well-established links to specific diagnoses, immunotherapy is not a standard or recognized treatment for severe major depressive disorder (MDD). This mismatch creates a clear query opportunity to clarify the diagnosis or the treatment plan.

Correct Option:

D. Severe major depressive disorder and immunotherapy
This is correct. Immunotherapy is a treatment used for conditions like cancer, autoimmune disorders, or severe allergies—not for major depressive disorder. This clinical inconsistency justifies a query to ask the provider to clarify the diagnosis being treated or to explain the rationale for using immunotherapy. This query opportunity focuses on diagnosis-treatment mismatch, which is a common and appropriate reason for a CDI query.

Incorrect Options:

A. Prostate carcinoma and luteinizing hormone-releasing hormone
This is incorrect. Luteinizing hormone-releasing hormone (LHRH) agonists (e.g., leuprolide) are a standard, well-established treatment for prostate carcinoma. This is a clinically appropriate link and does not require a query.

B. Atrial fibrillation and amiodarone
This is incorrect. Amiodarone is a widely used antiarrhythmic medication for the management of atrial fibrillation. This is a clinically appropriate and expected treatment relationship, so no query is warranted.

C. Malnutrition and parenteral nutrition
This is incorrect. Parenteral nutrition is a standard treatment for malnutrition when oral or enteral feeding is not possible or sufficient. This is a clinically appropriate link and does not generate a query opportunity.

Reference:

ACDIS/AHIMA "Guidelines for Achieving a Compliant Query Practice" – Queries are appropriate to clarify ambiguous, conflicting, or clinically inconsistent documentation, such as a diagnosis that does not match the treatment plan.

ICD-10-CM Official Guidelines – Coding should reflect the provider's documented diagnosis and treatment; discrepancies may require clarification.

Standard clinical practice – Immunotherapy is not indicated for major depressive disorder; this mismatch justifies a query.

CDI best practices – Queries should be based on clinical indicators, including unexpected or unsupported treatment relationships.

Explanation:
The patient is 6 weeks postpartum and presents with elevated blood pressure readings. The provider documents only "hypertension" without specifying whether it was pre-existing (chronic) or developed during pregnancy (gestational or pre-eclamptic). This distinction is critical for coding and risk adjustment, as the ICD-10-CM codes and clinical management differ significantly. The most appropriate query is to clarify the timing and etiology of the hypertension.

Correct Option:

B. Whether the hypertension was pre-existing or developed during pregnancy
This is correct. The patient is 6 weeks postpartum, and the provider documents hypertension without specifying if it is chronic (pre-existing) , gestational, or related to pre-eclampsia. This distinction is essential for accurate ICD-10-CM coding (O10-O11, O13-O16 vs. I10) and impacts both clinical management and risk adjustment. A query to clarify the etiology and timing of hypertension is clinically significant and compliant.

Incorrect Options:

A. A more specific diagnosis, such as pre-eclampsia or eclampsia
This is incorrect. The patient is 6 weeks postpartum, and the documented findings (blood pressure 154/90–160/88, slight headaches, no visual changes, no edema) do not provide sufficient clinical indicators for pre-eclampsia/eclampsia. The blood pressure readings are elevated, but without proteinuria, severe headaches, visual disturbances, or other systemic signs, querying for pre-eclampsia would be unsupported and leading.

C. Association of hypertension to smoking
This is incorrect. While smoking is a risk factor for cardiovascular disease, the provider has not documented any causal link between smoking and the current hypertension. Querying for this association would be speculative and not clinically significant for the immediate postpartum management or coding.

D. Hypertensive crisis - unspecified
This is incorrect. The blood pressure readings (154/90 and 160/88) do not meet the threshold for hypertensive crisis, which is typically defined as systolic BP >180 or diastolic BP >120. Querying for hypertensive crisis is not supported by the documented clinical indicators and would be non-compliant.

Reference:

ICD-10-CM Official Guidelines – Section I.C.15 (Pregnancy, Childbirth, and the Puerperium) – Codes O10-O16 require specificity regarding pre-existing vs. pregnancy-related hypertension.

ACOG Practice Bulletin – Hypertension in pregnancy is classified as chronic, gestational, or pre-eclamptic; timing is critical for diagnosis and coding.

ACDIS/AHIMA "Guidelines for Achieving a Compliant Query Practice" – Queries should be supported by clinical indicators and address clinically significant documentation gaps.

ICD-10-CM Guidelines – Postpartum hypertension should be clarified as chronic or pregnancy-related for accurate coding.

Querying for pre-eclampsia without supporting clinical indicators (e.g., proteinuria, severe symptoms) is non-compliant.

Explanation:
In the Medicare Shared Savings Program (MSSP), an Accountable Care Organization (ACO) is eligible for shared savings if it meets the quality performance standard and keeps actual costs below the benchmark. Here, the actual costs ($52M) exceed the expected costs ($50M), meaning the ACO overspent. Therefore, instead of receiving savings, the ACO may be subject to a shared loss (penalty), depending on the specific track and contract terms.

Correct Option:

B. The ACO will expect to pay back dollars in shared savings.
This is correct. Since the actual costs ($52M) exceeded the expected costs ($50M) by $2M, the ACO has not generated savings but rather a loss. Under MSSP rules, if an ACO's spending exceeds its benchmark, it may be responsible for repaying a portion of the excess (shared losses), depending on its selected risk track. The quality score of 90% meets the standard to qualify for shared savings, but since there are no savings, the ACO faces a penalty.

Incorrect Options:

A. The ACO will expect to receive dollars in shared savings.
This is incorrect. Shared savings are only earned when actual costs are below the benchmark. Here, actual costs ($52M) are higher than expected ($50M), so there are no savings to share. The ACO is not eligible to receive any shared savings payment.

C. The ACO will be eligible for shared savings after the second year.
This is incorrect. The MSSP performance period is annual; savings or losses are determined each year based on that year's performance, not only after the second or final year. The ACO's eligibility for savings or losses is assessed annually.

D. The ACO will have shared savings or penalty determined at the end of the agreement period.
This is incorrect. In the MSSP, financial reconciliation (savings or losses) occurs annually, not only at the end of the 3-year agreement period. Each performance year is independently evaluated for savings or losses.

Reference:

CMS Medicare Shared Savings Program – Shared savings are earned when actual costs are below the benchmark; losses are owed when actual costs exceed the benchmark.

CMS MSSP Final Rule – Financial reconciliation occurs annually; quality performance must be met to qualify for savings, but savings require cost below benchmark.

CMS MSSP – Shared losses are repaid by the ACO when spending exceeds the benchmark, depending on the risk track (e.g., Track 1, Track 2, Track 3).

CMS "Shared Savings and Losses" – If actual costs exceed the benchmark, the ACO owes CMS a portion of the excess (shared losses).

MSSP performance year – Savings/losses are determined for each performance year, not only at the end of the agreement period.

Explanation:
The patient has leukemia on the problem list, and the provider reviewed CBC/WBC and referred to an oncologist—indicating active management of this condition. However, the documentation lacks specificity regarding the status (remission or relapse) and acuity (acute vs. chronic) of leukemia. Capturing a more specific, high-weight condition like active leukemia has a significant impact on risk adjustment, as it is a hierarchical condition category (HCC) with high predictive weight.

Correct Option:

A. Status (remission, or relapse) and acuity of leukemia
This is correct. Leukemia is a high-weight HCC in the CMS-HCC and HHS-HCC risk adjustment models. The documentation shows active management (CBC/WBC review, oncology referral), but the status (remission, relapse, or active) and acuity (acute vs. chronic) are unclear. Clarifying these elements ensures accurate risk adjustment and reflects the patient's true severity of illness. This is the most impactful query opportunity due to the high weight of leukemia in risk models.

Incorrect Options:

B. Type (diastolic, systolic, combined) and acuity of heart failure
This is incorrect. While heart failure is also a high-weight HCC, the documentation already states "heart failure" was relevant to the encounter. However, the patient's leukemia is a more significant risk adjustment opportunity because it is a cancer diagnosis with higher predictive weight and the documentation suggests active management. Additionally, heart failure type/acuity is important, but leukemia status carries more weight in the risk model.

C. Differentiation of atrial fibrillation (paroxysmal, persistent, permanent)
This is incorrect. Atrial fibrillation is an HCC, but its risk weight is lower than leukemia. The documentation already includes atrial fibrillation as a relevant condition, but clarifying its type would not have as significant an impact on the risk score compared to specifying leukemia status and acuity.

D. Severity of the malnutrition (mild, moderate, severe)
This is incorrect. Malnutrition is an HCC, but it carries a lower weight than leukemia. While the provider's referral to a dietitian supports addressing nutritional status, the severity of malnutrition does not impact risk adjustment as significantly as clarifying the status and acuity of leukemia.

Reference:

CMS-HCC Risk Adjustment Model – Leukemia (HCC 8) has a very high risk score weight; heart failure (HCC 85) and atrial fibrillation (HCC 96) have lower weights.

ICD-10-CM Official Guidelines – Leukemia codes (C91-C95) require specificity for acute/chronic and remission/relapse status.

ACDIS/AHIMA "Guidelines for Achieving a Compliant Query Practice" – Queries should prioritize clinically significant conditions with high risk adjustment impact.

CMS-HCC model – Active malignancies and their status (remission/relapse) are critical for accurate risk prediction.

Malnutrition severity (mild/moderate/severe) is important but less impactful than leukemia specificity.

Explanation:
Both APCs (Ambulatory Payment Classifications) and DRGs (Diagnosis-Related Groups) are prospective payment systems used by CMS to reimburse providers. Their core similarity is that they both classify services or episodes of care into groups that are clinically similar and have comparable resource utilization. This ensures that payment reflects the typical costs associated with providing that type of care.

Correct Option:

C. APCs classify payment identifying similar resource use.
This is correct. APCs group outpatient services (procedures and ancillary services) that are clinically similar and have similar resource consumption. DRGs do the same for inpatient stays, grouping patients with similar diagnoses and procedures that consume similar hospital resources. The fundamental principle of grouping services by resource use is the key similarity between the two payment systems.

Incorrect Options:

A. Multiple APCs can be assigned for a given encounter.
This is incorrect because this describes a difference between APCs and DRGs. In the outpatient setting, multiple APCs can be assigned on a single claim (e.g., a procedure APC and a separate APC for ancillary services). In contrast, for inpatient DRGs, only one DRG is assigned per admission. This is a distinction, not a similarity.

B. APC assignment is dependent on diagnoses codes.
This is incorrect. APC assignment is primarily driven by CPT/HCPCS procedure codes (the services performed), not diagnosis codes. While diagnosis codes support medical necessity, they do not directly determine the APC. In contrast, DRG assignment relies heavily on both diagnosis and procedure codes, making this a key difference, not a similarity.

D. Only one APC can be assigned for a given encounter.
This is incorrect. In outpatient services, multiple APCs can be assigned for a single encounter (e.g., a visit with multiple procedures). This contrasts with inpatient DRGs, where only one DRG is assigned per admission. This is a difference, not a similarity.

Reference:

CMS Outpatient Prospective Payment System (OPPS) – APCs group services with similar clinical characteristics and resource utilization.

CMS Inpatient Prospective Payment System (IPPS) – DRGs group inpatient stays with similar resource consumption.

CMS "Medicare Payment Systems" – Both APCs and DRGs are prospective payment systems that classify by resource use.

CMS OPPS Fact Sheet – Multiple APCs can be assigned per encounter; only one DRG per inpatient stay.

AHIMA "Outpatient Coding and APC Reimbursement" – APCs rely on CPT/HCPCS codes, whereas DRGs use both ICD-10-CM and ICD-10-PCS codes.

Explanation:
The documentation already provides specific, codable diagnoses for most conditions: DM type 2 with peripheral neuropathy and diabetic ulcer (E11.62), hypertension (I10), morbid obesity (E66.01 with BMI 43), and chronic respiratory failure with COPD (J96.10, J44.9). However, the depth of the diabetic ulcer is not specified (e.g., limited to skin, involving fat, muscle, or bone). This specificity is critical for accurate ICD-10-CM coding, as codes for diabetic ulcers require details on the depth and extent of tissue involvement, which directly impacts severity and risk adjustment.

Correct Option:

D. Depth of diabetic ulcer
This is correct. The provider documents a "diabetic ulcer of the left great toe" but does not specify the depth or extent (e.g., skin layer, subcutaneous tissue, muscle, bone). ICD-10-CM codes for diabetic ulcers (E11.621, E11.622, E11.628) require this specificity. Clarifying the depth ensures accurate coding, reflects the true severity of the wound, and impacts risk adjustment by capturing the most precise diagnosis.

Incorrect Options:

A. Nicotine dependence
This is incorrect. The documentation already states the patient "stopped smoking 2 years ago." For nicotine dependence (F17.2-) to be coded, the patient must be currently dependent. Past tobacco use (Z87.891) is coded separately when documented, but the provider has already indicated cessation. Querying for nicotine dependence would not be supported and would not impact risk adjustment.

B. Diabetes with complications
This is incorrect. The documentation already specifies DM type 2 with peripheral neuropathy and diabetic ulcer, which clearly establishes diabetes with complications. No query is needed, as the complication is already fully documented and codable (E11.62).

C. Morbid obesity
This is incorrect. The documentation states "BMI 43," which qualifies for morbid obesity (E66.01). ICD-10-CM guidelines allow coding obesity based on BMI when documented by the provider. Since BMI 43 is already present, the condition is adequately documented and does not require a query.

Reference:

ICD-10-CM Official Guidelines – Section I.C.4.a.3 – Diabetic ulcers require specificity for site, laterality, and depth (e.g., E11.621 = ulcer of right foot with breakdown of skin; E11.622 = with fat layer exposed; E11.628 = with other specified severity).

ICD-10-CM Guidelines – Coding of diabetic ulcers requires documentation of the depth of tissue involvement.

ICD-10-CM Guidelines – Nicotine dependence requires current use; past use is coded as Z87.891.

ICD-10-CM Guidelines – BMI codes (Z68.-) are coded when documented; BMI 43 maps to morbid obesity (E66.01).

ACDIS/AHIMA "Guidelines for Achieving a Compliant Query Practice" – Queries should address clinically significant, ambiguous, or incomplete documentation; depth of ulcer is a specific and impactful query opportunity.

Explanation:
To calculate the final RAF (Risk Adjustment Factor) score, you must sum the demographic risk factor weight and the HCC weights for all documented, reportable diagnoses. However, if a patient has multiple HCCs that are hierarchical, only the highest-weighted HCC within a given disease hierarchy is counted. In this case, both diabetes with nephropathy and diabetes with retinopathy fall under the same diabetes hierarchy, so only the highest weight among them (0.166) is counted—not both.

Correct Option:

B. 0.797

This is correct. The calculation is:

Demographic weight: 0.332

Diabetes with nephropathy (0.166) and diabetes with retinopathy (0.166) are hierarchical—only the highest (0.166) is counted once.

Atrial fibrillation: 0.299

Total RAF = 0.332 + 0.166 + 0.299 = 0.797

Incorrect Options:

A. 0.932
This is incorrect because it incorrectly adds both diabetes HCCs (0.166 + 0.166) without applying the hierarchy rule, then adds the demographic weight (0.332) and atrial fibrillation (0.299). The total would be 0.332 + 0.166 + 0.166 + 0.299 = 0.963, which is not an option, but 0.932 also reflects an incorrect addition.

C. 1.418
This is incorrect. This number appears to be the sum of all weights without applying the hierarchy rule and possibly adding an extra value. It does not match the correct calculation.

D. 0.678
This is incorrect. This number appears to be the sum of the demographic weight (0.332) and only one of the diabetes HCCs (0.166) plus a partial or incorrect value, omitting the atrial fibrillation HCC (0.299) entirely.

Reference:

CMS-HCC Risk Adjustment Model – Hierarchical condition categories dictate that when multiple HCCs within the same disease hierarchy are documented, only the highest-weighted HCC is counted.

CMS-HCC model documentation – Diabetes HCCs (HCC 17, 18, 19) are hierarchical; only the most severe manifestation is counted.

CMS-HCC model – Atrial fibrillation (HCC 96) is in a separate hierarchy and is counted separately.

CMS-HCC model – Demographic factors (age, gender, Medicaid status) are added to the total RAF score.

ACDIS/AHIMA "CDI and Risk Adjustment" – RAF scores are calculated by summing demographic weight + unique non-hierarchical HCC weights.

Explanation:
The ICD-10-CM Official Guidelines for Coding and Reporting are divided into four sections. For outpatient coding, coders must apply Section I (conventions, general guidelines, and chapter-specific guidelines) and Section IV (specific guidelines for outpatient services). Section II applies to inpatient principal diagnosis selection, and Section III applies to inpatient reporting of additional diagnoses.

Correct Option:

D. Section I, Conventions, General Coding Guidelines and Chapter Specific Guidelines; and Section IV, Diagnostic Coding and Reporting Guidelines for Outpatient Services
This is correct. All coders, regardless of setting, must apply Section I for foundational coding conventions and chapter-specific rules. Section IV provides additional guidelines that are specific to outpatient services, including rules for coding uncertain diagnoses, preoperative evaluations, and routine outpatient visits. Together, these sections govern outpatient coding.

Incorrect Options:

A. Section I, Conventions, General Coding Guidelines, and Chapter Specific Guidelines
This is incorrect because it omits Section IV, which contains the outpatient-specific guidelines. While Section I is essential for all settings, outpatient coders must also apply Section IV for setting-specific rules. This option is incomplete.

B. Section IV, Diagnostic Coding and Reporting Guidelines for Outpatient Services
This is incorrect because it omits Section I. Outpatient coders must also apply the general conventions, chapter-specific guidelines, and general coding rules found in Section I. Section IV alone does not provide the complete coding framework.

C. Section III, Reporting Additional Diagnoses; and Section IV, Diagnostic Coding and Reporting Guidelines for Outpatient Services
This is incorrect. Section III applies to inpatient settings and addresses the reporting of additional diagnoses (e.g., UHDDS definitions). It does not apply to outpatient coding. Only Section I and Section IV are applicable to outpatient settings.

Reference:

ICD-10-CM Official Guidelines for Coding and Reporting – Introduction: The guidelines are divided into four sections.

ICD-10-CM Guidelines – Section I applies to all settings; Section II applies to inpatient principal diagnosis; Section III applies to inpatient additional diagnoses; Section IV applies to outpatient services.

ICD-10-CM Guidelines – Section IV includes outpatient-specific rules for coding uncertain diagnoses, observation, and preoperative evaluations.

CMS "ICD-10-CM Official Guidelines" – Outpatient coders must use both Section I and Section IV.

Explanation:
In this outpatient encounter, the patient presents with symptoms (stuffy nose, fever, fatigue) and the provider documents only symptoms without a definitive diagnosis for the acute condition. The provider does not specify an illness like a URI or influenza. In the outpatient setting, when a definitive diagnosis is not established, symptoms, signs, or abnormal findings should be coded as the first-listed diagnosis. The chronic conditions (DM, GERD, HTN) are documented but not actively addressed or managed during this visit, so they are not coded.

Correct Option:

B. Codes that describe symptoms and signs
This is correct. ICD-10-CM guidelines state that when a patient presents with symptoms and no definitive diagnosis is established by the provider, the symptoms should be coded. Here, the provider documented congestion (R09.81), fever (R50.9), and malaise (R53.83). Since the provider did not diagnose a specific condition (e.g., acute sinusitis, influenza), the symptoms are coded as the first-listed diagnoses. The chronic conditions were not evaluated or managed, so they are not coded for this encounter.

Incorrect Options:

A. Selection of first-listed condition
This is incorrect. While first-listed condition selection is a relevant guideline, it does not specifically apply to this scenario. The key issue here is that no definitive diagnosis was documented, and the symptoms are the only reportable conditions. The guideline for "Codes that describe symptoms and signs" is more directly applicable.

C. Uncertain diagnoses
This is incorrect. The provider did not document an uncertain diagnosis (e.g., "possible," "probable," "rule out," "suspected"). The provider only documented symptoms. The guideline for uncertain diagnoses applies when a provider documents a suspected condition (e.g., "rule out pneumonia"), which is not the case here.

D. Encounters for general medical examination with abnormal finding
This is incorrect. This is not a general medical examination (e.g., routine physical, wellness visit). It is a problem-focused encounter for acute symptoms. The guideline for general medical examinations does not apply.

Reference:

ICD-10-CM Official Guidelines for Coding and Reporting – Section I.B.5 – "Codes that describe symptoms and signs" – When no definitive diagnosis is established, code the symptoms.

ICD-10-CM Guidelines – Section IV.A – Outpatient coding: "Do not code diagnoses documented as 'probable,' 'suspected,' 'questionable,' 'rule out,' or 'working diagnosis'." Code the symptoms.

ICD-10-CM Guidelines – Section I.B.2 – "All documented conditions that coexist" – Chronic conditions should only be coded if they are evaluated, treated, or otherwise addressed during the encounter.

AHA Coding Clinic – Guidance on coding symptoms when no definitive diagnosis is documented.