Prepare to pass the CCS with hospital inpatient and outpatient coding practice

Answer:

When the provider is unable to clinically determine whether a condition was present at the time of admission, the POA indicator is W. B applies when the documentation is not sufficient and the provider has not stated that the timing is undetermined. C and D each require the provider to document a determination that was not made here.

Source: ICD-10-CM Official Guidelines for Coding and Reporting FY2027, Appendix I, Present on Admission Reporting Guidelines

Answer:

ICD-10-CM presumes a link between hypertension and heart failure, so I11.0 is used with an additional code for the type of heart failure, here I50.33 for acute on chronic diastolic failure. A ignores the presumed link. B omits the hypertension. C includes chronic kidney disease, which this patient does not have.

Source: ICD-10-CM Official Guidelines for Coding and Reporting FY2027, Section I.C.9.a.1

Answer:

Unstageable pressure ulcers are those whose stage cannot be clinically determined, for example because the base is covered by eschar, and they are coded to the unstageable code for the site. A and D estimate a stage that was not documented. C applies when there is no documentation of the stage, which differs from a documented unstageable ulcer.

Source: ICD-10-CM Official Guidelines for Coding and Reporting FY2027, Section I.C.12.a.2