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ACDIS Certified Clinical Documentation Specialist-Outpatient (CCDS-O) CCDS-O Question # 36 Topic 4 Discussion

ACDIS Certified Clinical Documentation Specialist-Outpatient (CCDS-O) CCDS-O Question # 36 Topic 4 Discussion

CCDS-O Exam Topic 4 Question 36 Discussion:
Question #: 36
Topic #: 4

A patient with a PMH of DM, GERD, and HTN is seen in the clinic with complaints of stuffy nose, fever, and feeling tired for the past four days. The patient’s medication list includes SSI, Prilosec, and Diovan. The provider documented: “Congestion, fever, malaise, DM, GERD, HTN. Continue OTC medications for congestion and fever. Rest. Return to the clinic in one week if symptoms persist.” Which of the following ICD-10-CM guidelines BEST applies to how this scenario should be coded?


A.

Selection of first-listed condition


B.

Codes that describe symptoms and signs


C.

Uncertain diagnoses


D.

Encounters for general medical examination with abnormal finding


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