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Codes can be assigned to diagnoses that are documented as being "probable", "suspected", "likely" in which setting? (inpatient or outpatient)


In which setting can any confirmed or definitive diagnoses be coded from the interpretation of a diagnostic test result?


In which setting would a CPT code be assigned for a herniorrhaphy?

Must be performed in an operating room

Which statement about a significant procedure is NOT true?
-Requires specialized training
-Carries an anesthetic risk
-Is surgical in nature
-Must be performed in an operating room

False, renal stone

True or False: The physician documents flank pain due to renal stone. The flank pain is the principal diagnosis.


True or False: In the inpatient setting, the physician documents suspected cholelithiasis in the discharge summary. The cholelithiasis is coded as if it exists.


True or False: The coder doesn't know if a diagnosis is present on admission, a POA (present on admission) indicator is NOT assigned.

Right upper quadrant pain, chronic cholecystitis, peptic ulcer disease

A patient is admitted with low-grade fever and right upper quadrant pain. The physician documents that the patient's right upper quadrant pain is due to chronic cholecystitis versus peptic ulcer disease. Which diagnoses should be reported?

Diabetes, type II

Patient is admitted with hyperglycemia due to new on-set diabetes, type II. Patient has had polydipsia, polyuria, and unexplained weight loss. Which diagnoses should be reported.


Patient is admitted with heartburn due to gastroesophageal reflux disease (GERD). Which diagnoses should be reported?

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