Coding Practice

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5. Follow your facilitators instructions to submit the assignment.

ICD-10-CM CODING: CHOOSING THE MAIN TERM

Code assignment begins by choosing a key or main term from the diagnostic statement. For each statement
below, choose which term is the main term to look up in the alphabetic index of the ICD-10-CM coding manual or
coding application search feature.

1. Attention-deficit/hyperactivity disorder (ADHD) 2. Chronic obstructive pulmonary disease (COPD)

MAIN TERM MAIN TERM

3. Heart disease 4. Acute bronchitis

MAIN TERM MAIN TERM

5. Sports physical 6. Otitis externa

MAIN TERM MAIN TERM

7. Chronic coughing 8. Abdominal hernia

MAIN TERM MAIN TERM

Current Procedural Terminology (CPT®) is a registered trademark of the American Medical Association.
CPT copyright 2020 American Medical Association. All rights reserved.

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ICD-10-CM CODING: ASSIGN THE CORRECT CODES

Use a current ICD-10-CM manual to assign the correct code for each of the following diagnostic statements.
Document the journey of key and sub terms used to locate the code. Remember to verify the code in the tabular
portion for completeness and accuracy.

1. Urticaria 2. Seasonal allergies

ICD-10-CM CODE ICD-10-CM CODE

JOURNEY JOURNEY

3. Screening for iron deficiency anemia 4. Dietary counseling and surveillance

ICD-10-CM CODE ICD-10-CM CODE

JOURNEY JOURNEY

5. Mild persistent asthma 6. Acne vulgaris

ICD-10-CM CODE ICD-10-CM CODE

JOURNEY JOURNEY

7. Atrial fibrillation 8. Pneumonia of the left lung

ICD-10-CM CODE ICD-10-CM CODE

JOURNEY JOURNEY

9. Dysmenorrhea 10. Fatigue

ICD-10-CM CODE ICD-10-CM CODE

JOURNEY JOURNEY

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11. Dysuria 12. Irregular menstrual periods

ICD-10-CM CODE ICD-10-CM CODE

JOURNEY JOURNEY

13. Speech delay 14. Bell’s palsy

ICD-10-CM CODE ICD-10-CM CODE

JOURNEY JOURNEY

15. Acute atopic conjunctivitis, bilateral 16. Dysfunctional uterine bleeding

ICD-10-CM CODE ICD-10-CM CODE

JOURNEY JOURNEY

17. Fever of unknown origin 18. Encounter for travel advice

ICD-10-CM CODE ICD-10-CM CODE

JOURNEY JOURNEY

19. Sickle-cell trait 20. Anemia complicating pregnancy, second trimester

ICD-10-CM CODE ICD-10-CM CODE

JOURNEY JOURNEY

21. Human papillomavirus infection (HPV) in female

patient 22. Cardiac murmur

ICD-10-CM CODE ICD-10-CM CODE

JOURNEY JOURNEY

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23. Pre-operative clearance 24. Morbid obesity

ICD-10-CM CODE ICD-10-CM CODE

JOURNEY JOURNEY

25. Borderline diabetes 26. Benign neoplasm of the pituitary gland

ICD-10-CM CODE ICD-10-CM CODE

JOURNEY JOURNEY

27. Family planning for contraceptives 28. IUD checkup

ICD-10-CM CODE ICD-10-CM CODE

JOURNEY JOURNEY

29. Routine gynecological examination 30. Acute vaginitis

ICD-10-CM CODE ICD-10-CM CODE

JOURNEY JOURNEY

31. Smoker 32. Systemic hypertension

ICD-10-CM CODE ICD-10-CM CODE

JOURNEY JOURNEY

33. Mixed hyperlipidemia 34. Senile cataracts, bilateral

ICD-10-CM CODE ICD-10-CM CODE

JOURNEY JOURNEY

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35. Adjustment disorder with anxiety 36. Genital herpes

ICD-10-CM CODE ICD-10-CM CODE

JOURNEY JOURNEY

37. Flexural eczema 38. Chlamydia

ICD-10-CM CODE ICD-10-CM CODE

JOURNEY JOURNEY

39. Colic 40. Seizures

ICD-10-CM CODE ICD-10-CM CODE

JOURNEY JOURNEY

41. Peanut allergy 42. Acute prostatitis

ICD-10-CM CODE ICD-10-CM CODE

JOURNEY JOURNEY

43. Gastroenteritis 44. Anxiety

ICD-10-CM CODE ICD-10-CM CODE

JOURNEY JOURNEY

45. Sore throat 46. Chiari malformation, type I

ICD-10-CM CODE ICD-10-CM CODE

JOURNEY JOURNEY

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47. Right ovarian cyst 48. Pregnancy test, negative

ICD-10-CM CODE ICD-10-CM CODE

JOURNEY JOURNEY

49. Obesity complicating pregnancy, third trimester 50. Diabetes mellitus type II with hyperglycemia

ICD-10-CM CODE ICD-10-CM CODE

JOURNEY JOURNEY

51. Cardiac arrhythmia 52. Latent syphilis

ICD-10-CM CODE ICD-10-CM CODE

JOURNEY JOURNEY

53. Coronary artery disease (CAD) 54. Total hysterectomy status

ICD-10-CM CODE ICD-10-CM CODE

JOURNEY JOURNEY

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CPT CODING: ASSIGN THE CORRECT CODE

Use a current CPT® coding manual to assign the correct code to the following services/encounters. Document
the journey of key and sub terms used to locate the code. Remember to verify the code in the tabular portion for
completeness and accuracy.

1. Hemoglobin cell count 2. Performance measure; BMI documented

CPT CODE CPT CODE

JOURNEY JOURNEY

3. Performance measure; Depression screening

performed 4. Urinalysis, dipstick

CPT CODE CPT CODE

JOURNEY JOURNEY

5. Pregnancy test 6. Telephone E/M encounter lasting 12 minutes

CPT CODE CPT CODE

JOURNEY JOURNEY

7. Individual psychotherapy, 30 minute session 8. Intensive smoking cessation counseling

CPT CODE CPT CODE

JOURNEY JOURNEY

9. Chronic care management services, total

monthly time of 15 minutes 10. Tendon injection (single) of plantar fascia

CPT CODE CPT CODE

JOURNEY JOURNEY

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11. Spirometry, total capacity with expiratory flow 12. Office encounter, established patient with low
rate measurement medical decision-making

CPT CODE CPT CODE

JOURNEY JOURNEY

13. Office encounter, new patient, 45 minutes

documented

CPT CODE

JOURNEY

CPT AND ICD-10-CM CODING SCENARIOS: ASSIGN THE CORRECT CODE

Use current ICD-10-CM, CPT, and HCPCS coding manuals to assign the correct diagnosis and service/encounter
code to the following patient scenarios. Document the journey of key and sub terms used to locate the code.
Remember to verify the code in the tabular portion for completeness and accuracy.

Scenario 1 A 2-year-old child presented for a well child encounter. Patient also received hepatitis A,
Prevnar 13, and Hib vaccines, including counseling for each vaccine administered. What ICD-10-CM and
CPT code should be reported for this service?

CPT CODES

ICD-10-CM CODES

JOURNEY

Scenario 2 Encounter is for a preventive exam of an established 31-year-old patient with abnormal ECG.
What ICD-10-CM and CPT codes should be reported for this service?

CPT CODES

ICD-10-CM CODES

JOURNEY

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Scenario 3 Established PPO patient Deyal Patel was seen today for recurring low-back pain. During the
visit, the provider ordered and obtained a two-view X-ray of the lumbosacral spine. Ms. Patel also reported
three skin tags on her neck, and the provider removed the skin tags during the visit. At the end of the visit,
the provider ordered and provided a custom-fit back brace for support of Ms. Patel’s low-back pain. The
visit lasted 25 minutes. What ICD-10-CM, CPT, and HCPCS codes should be reported for these services?

CPT CODES

ICD-10-CM CODES

HCPCS CODES

JOURNEY

Scenario 4 Established Medicare patient Jesus Robles has requested his primary care provider to
authorize home health services upon release from the hospital for right-knee replacement surgery. The
provider authorizes home health services for 30 days. What ICD-10-CM and HCPCS codes should be
reported for this service?

ICD-10-CM CODES

HCPCS CODES

JOURNEY

Scenario 5 A 39-year-old female patient presents to her primary care provider with absence of menses.
A urine pregnancy test is performed by the office staff using the Hybritech ICON (qualitative visual color
comparison test). What CPT codes should be reported for the urinalysis?

CPT CODES

JOURNEY

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BILLING PRACTICE 1
Referring to Scenario 3 above and the Patient Demographics form, complete the fillable CMS-1500 form..

Visit Scenario
Established PPO patient Deyal Patel (account ID: 42539528) was seen today for recurring low-back pain. During
the visit, the provider ordered an X-ray. Ms. Patel also reported three skin tags on her neck, and the provider
removed the skin tags during the visit. At the end of the visit, the provider ordered and provided a custom-fit back
brace for support of Ms. Patel’s low-back pain. The visit lasted 25 minutes.

Patient Information
⦁ DOB: 01/07/1979
⦁ Sex: Female
⦁ Address: 913 Blossom Drive, Yourtown, KS, 66212
⦁ Telephone: (913) 555-9481
⦁ Insurance: Group Health Plan: NHA FlexiPlan PPO

Treatment Costs
⦁ Established patient/office visit – 25 minutes; fee $125.00
⦁ Spine Lumbosacral 2/3 views; fee $ 35.00
⦁ Removal of three skin tags; fee $ 95.00
⦁ Back brace; fee/cost $350.00

Clinic and Provider Information

⦁ Clinic: ABC Clinic, 101 Anystreet, Mytown, KS 66211, phone # 913-555-0000; NPI 9876543210
⦁ PCP: Gabriella Torres, NPI 0123456789

BILLING PRACTICE 2
Using CMS-1500 form 2, complete the form using any of the above scenarios or create your own scenario(s) for
additional practice.

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CMS-1500 FORM 1

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CMS-1500 FORM 2

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