The scenario describes a patient presenting with symptoms suggestive of a urinary tract infection (UTI) and a history of hypertension. The physician performs a comprehensive history and physical, orders urinalysis and urine culture, and initiates antibiotic therapy. The physician also reviews the patient’s current hypertension management and provides counseling on lifestyle modifications. To accurately code this encounter for Certified Family Practice Coder (CFPC) University’s rigorous curriculum, one must consider the coding guidelines for both ICD-10-CM and CPT. For ICD-10-CM, the primary diagnosis is the UTI. Given the documentation of a confirmed UTI via urinalysis and culture, the most specific code is N39.0 (Urinary tract infection, site not specified). The patient’s hypertension is a co-existing condition that requires coding. The documentation indicates it is essential for the physician’s management decisions, thus it should be coded as I10 (Essential (primary) hypertension). For CPT coding, the encounter involves a detailed history and physical examination, diagnostic tests (urinalysis and culture), and medical decision-making. The physician’s actions align with an established patient visit. Considering the complexity of the history, examination, and medical decision-making, the appropriate E/M code would be 99214 (Office or other outpatient visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: a detailed history; a detailed examination; medical decision making of moderate complexity). The urinalysis and urine culture are diagnostic tests. The urinalysis is typically bundled into the E/M service when performed in the office. However, the urine culture, being a separate laboratory procedure, would be coded with 87086 (Culture, bacterial; urine, with isolation, unless otherwise specified). Therefore, the correct coding combination reflects the primary diagnosis, relevant co-existing conditions, the appropriate E/M service level, and the separately billable laboratory procedure. The explanation emphasizes the importance of specificity in ICD-10-CM coding and the selection of the correct E/M level based on the documented history, examination, and medical decision-making, as well as identifying separately billable procedures, all critical components of advanced family practice coding at Certified Family Practice Coder (CFPC) University.

The scenario describes a patient presenting with symptoms indicative of a urinary tract infection (UTI). The physician performs a urinalysis and a urine culture and sensitivity (C&S) test. The urinalysis, a qualitative and semi-quantitative examination, is typically reported using CPT codes from the Pathology and Laboratory section. Specifically, a routine urinalysis with microscopy is coded as 81001. The urine culture and sensitivity, which identifies the specific pathogen and its susceptibility to various antibiotics, is a more complex laboratory procedure. The CPT code for a urine culture, including isolation and identification of microorganisms, is 87086. The sensitivity testing, which determines the effectiveness of antibiotics, is reported with CPT code 87088. Therefore, the correct combination of codes to represent these services is 81001, 87086, and 87088. This selection reflects the distinct laboratory procedures performed and aligns with the CPT coding guidelines for pathology and laboratory services, emphasizing the need for accurate code assignment based on the documented services. Understanding the nuances between different laboratory tests and their corresponding CPT codes is fundamental for accurate billing and reimbursement, a core competency for Certified Family Practice Coders at CFPC University.

The scenario presented involves a patient with a history of Type 2 diabetes mellitus and hypertension, who presents for a routine follow-up visit. The physician documents that the patient’s blood glucose levels are well-controlled with oral medication, and their blood pressure is also within the target range. The physician also notes a new complaint of mild, intermittent epigastric discomfort that is not associated with meals and does not radiate. After a physical examination, the physician diagnoses “gastritis” and prescribes a proton pump inhibitor. To accurately code this encounter for Certified Family Practice Coder (CFPC) University’s rigorous curriculum, one must consider the principles of ICD-10-CM coding for multiple conditions and the nuances of Evaluation and Management (E/M) coding. The patient has two chronic conditions that are being managed: Type 2 diabetes mellitus and hypertension. These conditions are not explicitly stated as the reason for the visit, but they are part of the patient’s ongoing medical history and are being monitored. The new complaint of epigastric discomfort leading to a diagnosis of gastritis is the primary reason for the encounter, but the management of the chronic conditions also contributes to the overall complexity of the visit. According to ICD-10-CM Official Guidelines for Coding and Reporting, when a patient with a known chronic condition presents for an encounter for a specific symptom or condition that is not related to the chronic condition, and the chronic condition is managed or monitored during the visit, the chronic condition should be coded. In this case, both Type 2 diabetes mellitus and hypertension are chronic conditions that are being managed. The gastritis is a new diagnosis. Therefore, the coding should reflect all three conditions. For E/M coding, the level of service is determined by medical decision making (MDM) or time. In this scenario, the physician is managing multiple chronic conditions with exacerbation or progression, and a new problem with uncertain prognosis. The physician is also ordering prescription drugs, which is a factor in MDM. The physician is addressing two chronic conditions with status-monitoring and management, and one new problem with evaluation and a prescription. This level of complexity supports a higher level of E/M service. The correct coding sequence would prioritize the primary reason for the visit, which is the gastritis. However, the management of the diabetes and hypertension are integral to the overall care provided during this encounter and contribute to the medical decision making. Therefore, the codes for diabetes and hypertension should also be reported. The specific ICD-10-CM codes would be K29.70 for gastritis, unspecified, without bleeding, E11.9 for Type 2 diabetes mellitus without complications, and I10 for essential (primary) hypertension. The E/M code would be selected based on the physician’s documentation of the encounter’s complexity, considering the number and complexity of problems addressed, the amount and complexity of data to be reviewed and analyzed, and the risk of complications or death or permanent impairment. The correct approach involves identifying all conditions that were addressed and managed during the encounter. The gastritis is the acute or primary diagnosis. The Type 2 diabetes mellitus and hypertension are chronic conditions that are being monitored and managed, and thus should also be reported. The ICD-10-CM codes for these conditions are K29.70, E11.9, and I10, respectively.

The scenario describes a patient presenting with symptoms of a urinary tract infection (UTI). The physician performs a urinalysis and a urine culture and sensitivity (C&S) test. The urinalysis results indicate the presence of leukocytes and nitrites, which are indicative of a UTI. The urine culture identifies *Escherichia coli* (E. coli) as the causative organism and sensitivity testing reveals that the E. coli is susceptible to nitrofurantoin but resistant to ampicillin. For coding purposes, the primary diagnosis is the UTI. ICD-10-CM code N39.0 (Urinary tract infection, site not specified) is appropriate for this condition. The physician’s encounter involves a moderate level of medical decision making, considering the two diagnoses (UTI and the identified organism), the need for two diagnostic tests (urinalysis and urine culture/sensitivity), and the interpretation of moderate complexity of the test results. This aligns with the criteria for a Level 3 Outpatient Consultation (CPT code 99243) or a New Patient Office Visit, established problem, moderate level of complexity (CPT code 99203), depending on the patient’s status and the specific E/M guidelines being applied. However, the question focuses on the diagnostic tests themselves. The urinalysis is a laboratory procedure, typically coded using CPT codes from the Pathology and Laboratory section. A standard urinalysis with microscopy is often coded as 81001 (Urinalysis, microscopic only). The urine culture and sensitivity is also a laboratory procedure. A urine culture, identifying pathogen(s), with sensitivity testing is coded as 87088 (Culture, bacterial; urine, with isolation, with identification and with sensitivity studies). Therefore, the correct combination of codes to represent the diagnostic tests performed is 81001 for the urinalysis and 87088 for the urine culture and sensitivity. The explanation of why this is correct lies in accurately identifying the services rendered and mapping them to their corresponding CPT codes as per the AMA’s Current Procedural Terminology manual. This requires understanding the scope of each test and the specific descriptors within the CPT code set, which is a fundamental skill for a Certified Family Practice Coder at CFPC University. The selection of these codes reflects the coder’s ability to translate clinical services into billable entities, ensuring accurate reimbursement and compliance with coding standards, a core competency emphasized in CFPC University’s curriculum.

The scenario describes a patient presenting with symptoms indicative of an acute exacerbation of chronic obstructive pulmonary disease (COPD). The physician’s documentation notes the presence of a secondary bacterial infection, specifically pneumonia, complicating the COPD. According to ICD-10-CM Official Guidelines for Coding and Reporting, when a condition is exacerbated by another condition, and the documentation clearly links them, both conditions should be coded. Specifically, for COPD with exacerbation, the guidelines direct coders to first assign the code for the COPD (J44.9, Chronic obstructive pulmonary disease, unspecified) and then append a code for the exacerbation. However, the presence of pneumonia as a complicating factor requires further specificity. The guidelines also state that if a patient has COPD and develops pneumonia, and the pneumonia is documented as the reason for the encounter or a significant condition, the pneumonia code should be sequenced first, followed by the COPD code. In this case, the pneumonia is explicitly stated as a complication of the COPD exacerbation. Therefore, the appropriate coding sequence involves identifying the code for pneumonia and then the code for the COPD with exacerbation. Given the documentation of a secondary bacterial infection, pneumonia (J18.9, Pneumonia, unspecified organism) is the primary diagnosis driving the current treatment. The COPD, while a chronic condition, is being managed in the context of this acute infectious process. The exacerbation of COPD is a consequence of the pneumonia. Therefore, the most accurate coding reflects the acute, complicating condition first. The ICD-10-CM index would lead to J18.9 for unspecified pneumonia. For the COPD, while J44.1 (Chronic obstructive pulmonary disease with (acute) exacerbation) could be considered, the presence of pneumonia as the complicating factor means the pneumonia code takes precedence in sequencing, and the COPD is then coded to reflect its underlying presence. However, the question asks for the *most specific* coding for the *primary reason for the encounter* as described by the physician’s focus on the infection. The physician’s documentation emphasizes the bacterial infection as a complication. Therefore, the code for pneumonia should be sequenced first. The COPD is a pre-existing condition that is being managed alongside the pneumonia. The ICD-10-CM guidelines for coding complications of chronic conditions, particularly when an acute infection exacerbates a chronic respiratory illness, prioritize the acute infectious process. Thus, J18.9 is the correct primary code. The COPD itself, without further specification of exacerbation *independent* of the pneumonia, would be coded as J44.9 if the exacerbation is solely attributed to the pneumonia. However, if the physician explicitly states an exacerbation *of* the COPD *due to* the pneumonia, then J44.1 would be appropriate as the secondary diagnosis. The question implies the pneumonia is the direct cause of the acute presentation. Therefore, the most accurate representation is to code the pneumonia first.

The scenario describes a patient presenting with symptoms consistent with a urinary tract infection (UTI). The physician performs a urinalysis and a urine culture and sensitivity (C&S) to confirm the diagnosis and identify the causative organism and its antibiotic susceptibility. The ICD-10-CM code for a confirmed UTI, specifically cystitis without hematuria, is N30.00. The CPT code for a urinalysis, which includes microscopic examination, is 81001. The CPT code for a urine culture and sensitivity, which involves identifying the organism and testing its susceptibility to various antibiotics, is 87088. When multiple procedures are performed during the same encounter, and they are distinct and separately identifiable, coders must report each service. In this case, the urinalysis and the urine culture and sensitivity are distinct laboratory procedures. Therefore, both 81001 and 87088 should be reported. The ICD-10-CM code N30.00 accurately reflects the diagnosed condition. The combination of N30.00, 81001, and 87088 represents the complete and accurate coding for this encounter, reflecting the diagnostic workup and the confirmed condition. This approach aligns with the principles of accurate medical coding taught at Certified Family Practice Coder (CFPC) University, emphasizing the importance of capturing all services rendered and the precise diagnosis for proper reimbursement and data integrity. Understanding the nuances of laboratory test coding and diagnostic coding is fundamental to the curriculum at CFPC University, preparing students for the complexities of real-world healthcare billing and documentation.

The scenario describes a patient presenting with symptoms that could be attributed to multiple underlying conditions, necessitating careful coding to reflect the most accurate and specific diagnosis. The physician’s documentation notes “acute exacerbation of chronic obstructive pulmonary disease (COPD)” and also mentions “bronchospasm.” In ICD-10-CM coding, the principle of coding to the highest level of specificity applies. While bronchospasm is present, it is a symptom or manifestation of the COPD exacerbation. The primary diagnosis driving the encounter and treatment is the acute exacerbation of COPD. Therefore, the most appropriate ICD-10-CM code would reflect this specific condition. The presence of bronchospasm, if not independently significant or the primary reason for the visit, is typically subsumed within the exacerbation code. The guidelines for coding respiratory conditions, particularly COPD, emphasize capturing the acute exacerbation over mere symptomatic presentation. Thus, a code that specifically denotes an acute exacerbation of COPD is paramount.

The scenario involves a patient presenting with symptoms suggestive of a urinary tract infection (UTI) and a concurrent diagnosis of hypertension. The physician performs a comprehensive history, detailed physical examination, and orders laboratory tests, including a urinalysis and urine culture. The physician also reviews the patient’s existing medication list for hypertension management. The coding of this encounter requires careful consideration of ICD-10-CM and CPT guidelines. For ICD-10-CM, the primary diagnosis is the UTI. Given the urinalysis and culture results confirming a bacterial infection, the most specific code for a bacterial UTI would be selected. If the physician documented the specific organism, an even more precise code might be applicable, but based on the provided information, a general bacterial UTI code is appropriate. The hypertension is a co-existing condition that should also be coded. If the hypertension is stated to be controlled or managed, a code reflecting that status would be used. If the physician notes that the hypertension is a factor influencing the current encounter or treatment, it would be coded as a secondary diagnosis. For CPT, the coding would depend on the complexity of the Evaluation and Management (E/M) service provided. Given the detailed history, physical exam, and ordering of diagnostic tests, the encounter likely qualifies for a moderate to high level of E/M service. The specific E/M code would be determined by the Medical Decision Making (MDM) component, which considers the number and complexity of problems addressed, the amount and/or complexity of data to be reviewed and analyzed, and the risk of complications or death or morbidity or mortality of patient management. The urinalysis and urine culture would be coded using appropriate CPT codes from the Pathology and Laboratory section. Therefore, the correct coding approach involves identifying the principal diagnosis (UTI), secondary diagnoses (hypertension), and the appropriate E/M service level, along with the diagnostic tests performed. The selection of the most specific ICD-10-CM codes and the accurate CPT code for the E/M service, considering the MDM, is crucial for accurate billing and reimbursement at Certified Family Practice Coder (CFPC) University.

The scenario describes a patient presenting with symptoms consistent with a urinary tract infection (UTI). The physician’s documentation notes “dysuria” and “urinary frequency.” The ICD-10-CM coding guidelines for UTIs require specificity. While “dysuria” and “urinary frequency” are symptoms, they are not the definitive diagnosis. The physician’s assessment, however, does not explicitly state “urinary tract infection.” Instead, it lists “suspected UTI.” In ICD-10-CM, when a condition is suspected or probable, but not confirmed, coders are instructed to code the signs and symptoms that are documented. Therefore, the most accurate coding in this situation, based on the provided documentation and the principle of coding signs and symptoms when a definitive diagnosis is not established, would be to report the documented symptoms. The ICD-10-CM codes for dysuria and urinary frequency are N39.492 and R35.0, respectively. The question asks for the *most appropriate* coding approach given the documentation. Coding a definitive UTI (e.g., N39.0) would be incorrect as the physician documented “suspected UTI” and did not provide a confirmed diagnosis. Coding only the symptoms without acknowledging the suspected diagnosis is also not ideal if the suspicion itself is a significant part of the encounter. However, ICD-10-CM guidelines direct coders to code signs and symptoms when a definitive diagnosis is not made. Therefore, reporting the specific symptoms documented is the correct approach. The explanation of why this is correct lies in the fundamental principle of ICD-10-CM coding: code to the highest level of specificity documented. When a definitive diagnosis is not established, the documented signs and symptoms are to be coded. This ensures accurate representation of the patient’s condition at the time of service, which is crucial for reimbursement, statistical analysis, and continuity of care. The presence of “suspected UTI” indicates the physician’s clinical suspicion, but without further confirmation or a definitive diagnostic statement, the coder must rely on the explicitly stated symptoms. This aligns with the ethical and professional responsibilities of a Certified Family Practice Coder at Certified Family Practice Coder (CFPC) University, emphasizing precision and adherence to coding standards.

The scenario describes a patient presenting with symptoms consistent with a urinary tract infection (UTI). The physician performs a urinalysis and a urine culture and sensitivity (C&S) to confirm the diagnosis and identify the causative organism and appropriate antibiotic. The ICD-10-CM code for a confirmed UTI, specifically cystitis without hematuria, is N30.00. The CPT code for a urinalysis without microscopy is 81000. The CPT code for a urine culture and sensitivity, which includes identifying the organism and determining its susceptibility to antibiotics, is 87086. When multiple diagnostic procedures are performed on the same day, and one is a more comprehensive test that includes components of another, the more comprehensive test is typically reported. In this case, the urine culture and sensitivity (87086) inherently includes the identification of organisms, which is a component of a basic culture. However, the urinalysis (81000) is a separate and distinct test that examines physical and chemical properties of urine, not just microbial presence. Therefore, both 81000 and 87086 are appropriate to report. The question asks for the most accurate coding for the physician’s services based on the provided documentation. The ICD-10-CM code N30.00 accurately reflects the diagnosis of cystitis without hematuria. The CPT codes 81000 for the urinalysis and 87086 for the urine culture and sensitivity are correctly assigned based on the procedures performed. Therefore, the combination of N30.00, 81000, and 87086 represents the most accurate coding.

The scenario describes a patient presenting with symptoms that could be attributed to multiple conditions. The physician performs a comprehensive history and physical examination, orders laboratory tests (CBC, CMP), and a diagnostic imaging study (abdominal ultrasound). Based on the findings, the physician diagnoses acute cholecystitis and initiates a treatment plan. To correctly code this encounter for Certified Family Practice Coder (CFPC) University’s curriculum, we must consider the Evaluation and Management (E/M) coding guidelines and the appropriate diagnostic code. The E/M coding is determined by the level of medical decision making (MDM) or time spent. In this case, the physician addressed multiple problems of moderate severity (acute cholecystitis, potential dehydration from vomiting), ordered multiple diagnostic tests (CBC, CMP, abdominal ultrasound), and managed the condition with prescription medication and a referral for surgical consultation. This complexity points to a higher level of MDM. For the diagnostic coding, acute cholecystitis is the definitive diagnosis. According to ICD-10-CM, acute cholecystitis is coded as K81.0. The symptoms leading to the diagnosis (e.g., abdominal pain, nausea, vomiting) are typically not coded separately when a definitive diagnosis is established, unless they are being managed independently or are not integral to the diagnosis. Considering the E/M component, the physician’s actions involved moderate complexity in medical decision making. This would align with a specific E/M code level, such as an established patient office visit, level 4 (99214), or a new patient office visit, level 3 (99203), depending on the patient’s status and the total time spent if that methodology were used. However, the question focuses on the *most appropriate* diagnostic code given the information. The definitive diagnosis of acute cholecystitis is the primary focus for accurate coding and subsequent reimbursement. Therefore, K81.0 is the most precise code to represent the patient’s condition as documented.

The scenario describes a patient presenting with symptoms indicative of a urinary tract infection (UTI). The physician performs a urinalysis and a urine culture and sensitivity (C&S) test. The urinalysis, a qualitative and semi-quantitative examination of urine, is typically reported using CPT codes from the Pathology and Laboratory section. Specifically, a routine urinalysis with microscopy is often reported with CPT code 81001. The urine culture and sensitivity, a more complex laboratory procedure to identify and quantify microorganisms and determine their susceptibility to antibiotics, is reported with CPT code 87088. When multiple distinct laboratory procedures are performed on the same specimen, each procedure should be reported separately. Therefore, the correct coding for this encounter, focusing on the laboratory services provided, involves reporting both the urinalysis and the urine culture and sensitivity. The explanation of why this is the correct approach involves understanding the distinct nature of each laboratory test, their respective CPT code definitions, and the principle of reporting each separately when performed. This demonstrates a nuanced understanding of laboratory coding beyond simply identifying a single diagnosis.

The scenario describes a patient presenting with symptoms suggestive of a urinary tract infection (UTI). The physician documents “cystitis, unspecified” and also notes “dysuria” and “frequency of urination.” According to ICD-10-CM Official Guidelines for Coding and Reporting, when a definitive diagnosis has been established, that diagnosis should be reported. However, if a condition is documented as “unspecified,” coders must look for further specificity in the documentation. In this case, while “cystitis, unspecified” is documented, the physician also explicitly notes “dysuria” and “frequency of urination.” These are symptoms that are integral to the definition of cystitis and are often considered manifestations of it. ICD-10-CM guidelines generally advise against coding signs and symptoms when a definitive diagnosis that explains those symptoms has been established. Therefore, the most accurate coding approach is to report the definitive diagnosis of cystitis. The ICD-10-CM code for cystitis, unspecified, is N30.90. The presence of dysuria and frequency, while important clinical indicators, do not warrant separate coding as they are inherent to the condition of cystitis and are not documented as separate, unrelated conditions. The question tests the understanding of the principle of coding the most specific diagnosis and avoiding redundancy by coding integral symptoms.

The scenario involves a patient presenting with symptoms suggestive of a urinary tract infection (UTI) and a history of hypertension. The physician performs a comprehensive history and physical examination, orders a urinalysis, and prescribes an antibiotic. The physician also reviews the patient’s current hypertension medication and advises on lifestyle modifications. To accurately code this encounter for Certified Family Practice Coder (CFPC) University’s rigorous curriculum, a coder must consider multiple coding principles. The primary diagnosis is the UTI. Based on the provided information, the most specific ICD-10-CM code for an uncomplicated UTI, assuming no further details are given about the specific organism or site, would be N39.0 (Urinary tract infection, site not specified). The physician’s management of hypertension is a secondary, but significant, condition that requires coding. Since the physician is reviewing and managing the existing hypertension, the appropriate ICD-10-CM code is I10 (Essential (primary) hypertension). The encounter also involves the prescription of an antibiotic and the management of a chronic condition (hypertension), which may influence E/M coding and potentially require modifiers if specific services are separately billable or if the complexity warrants it. However, the question focuses on the primary diagnostic coding. The question tests the ability to identify the principal diagnosis and relevant secondary diagnoses from a clinical vignette, applying the ICD-10-CM coding guidelines. It requires understanding the specificity of codes and the importance of capturing all conditions that affect patient care and management during the encounter. The selection of N39.0 reflects the most accurate representation of the UTI as described, and I10 captures the co-existing hypertension managed during the visit. The rationale for choosing these codes is based on the principle of coding to the highest level of specificity documented and capturing all conditions that impact patient care.

The scenario presented involves a patient with a history of Type 2 diabetes mellitus, currently managed with oral medication, who presents with symptoms of a urinary tract infection (UTI). The physician documents “acute cystitis” and “Type 2 diabetes mellitus with hyperglycemia.” The crucial aspect for accurate coding at Certified Family Practice Coder (CFPC) University is understanding the hierarchical nature of ICD-10-CM coding and the impact of combination codes. The primary diagnosis is acute cystitis. However, the documentation also specifies Type 2 diabetes mellitus with hyperglycemia. ICD-10-CM guidelines dictate that when a patient has diabetes and a condition that is commonly associated with or exacerbated by diabetes, and the documentation links the two, the diabetes code should be sequenced first, followed by the manifestation code. In this case, hyperglycemia is a direct complication of Type 2 diabetes mellitus. Therefore, the correct coding approach involves identifying the ICD-10-CM codes for both conditions and sequencing them appropriately. The ICD-10-CM code for Type 2 diabetes mellitus with hyperglycemia is E11.65. The ICD-10-CM code for acute cystitis is N30.00. According to ICD-10-CM Official Guidelines for Coding and Reporting, when a patient has diabetes mellitus with hyperglycemia, and the hyperglycemia is documented, the code for diabetes with hyperglycemia should be assigned. Furthermore, for conditions that are commonly associated with diabetes, such as infections, if the physician documents a causal relationship or if the condition is exacerbated by diabetes, the diabetes code should be sequenced first. In this scenario, the physician has documented both conditions, and the hyperglycemia is directly linked to the Type 2 diabetes. The cystitis is a separate condition, but the presence of diabetes with hyperglycemia is a significant factor in the patient’s overall clinical picture. Therefore, the correct sequencing is to list the diabetes with hyperglycemia first, followed by the acute cystitis. This reflects the patient’s underlying chronic condition and its current manifestation, which is a core principle taught in advanced coding courses at Certified Family Practice Coder (CFPC) University, emphasizing the importance of comprehensive patient data for accurate reimbursement and clinical analysis.

The scenario describes a patient presenting with symptoms indicative of a urinary tract infection (UTI) and a concurrent diagnosis of type 2 diabetes mellitus. The physician performs a comprehensive history, detailed physical examination, and orders laboratory tests, including a urinalysis and urine culture. The patient’s diabetes is also managed during this encounter. To accurately code this encounter for a Certified Family Practice Coder at Certified Family Practice Coder (CFPC) University, one must consider the ICD-10-CM coding guidelines for multiple conditions and the CPT coding for the services rendered. For ICD-10-CM, the primary diagnosis is the UTI. Given the symptoms and diagnostic workup, a specific code for cystitis due to a bacterial agent is appropriate. The presence of diabetes mellitus, a chronic condition that can influence the management and outcome of the UTI, requires a secondary code. ICD-10-CM guidelines stipulate that when a patient has diabetes and a condition that is influenced by diabetes, the diabetes code should be sequenced first, followed by the condition. Therefore, the code for type 2 diabetes mellitus with hyperglycemia (if documented) or without complications, followed by the code for bacterial cystitis, is the correct approach. For CPT coding, the encounter involves both an evaluation and management (E/M) service and potentially a procedure. The E/M service would be coded based on the medical decision making (MDM) or time spent, considering the complexity of managing both the UTI and the diabetes. The urinalysis and urine culture are diagnostic tests. If performed in the physician’s office, the laboratory tests themselves would be coded using appropriate CPT codes for the procedures. However, the question focuses on the diagnostic coding aspect. The core principle tested here is the hierarchical sequencing of diagnoses in ICD-10-CM when one condition affects the management of another, and the understanding of how to represent co-existing conditions. The correct ICD-10-CM coding would involve identifying the most specific code for the UTI and then linking it appropriately with the diabetes diagnosis, ensuring the diabetes is listed first as per guidelines for conditions influenced by diabetes. The correct ICD-10-CM code for bacterial cystitis is N30.00. The correct ICD-10-CM code for type 2 diabetes mellitus with hyperglycemia is E11.65. According to ICD-10-CM Official Guidelines for Coding and Reporting, when a patient has diabetes mellitus and a condition that is influenced by the diabetes, the diabetes code should be sequenced first. Therefore, E11.65 should be sequenced before N30.00.

The scenario presented involves a patient diagnosed with both type 2 diabetes mellitus with hyperglycemia and diabetic nephropathy. The physician’s documentation also indicates a history of smoking, which is now considered “in remission” as the patient has not smoked for over a year. For the ICD-10-CM coding, we need to identify the principal diagnosis and any secondary diagnoses. The principal diagnosis is the condition chiefly responsible for the admission or encounter. In this case, the type 2 diabetes mellitus with hyperglycemia is the primary condition being managed. The ICD-10-CM code for type 2 diabetes mellitus with hyperglycemia is E11.65. The diabetic nephropathy is a complication of the diabetes, so it is coded as a secondary diagnosis. The ICD-10-CM code for diabetic nephropathy is E11.22. The history of smoking, now in remission, is coded using Z codes. The appropriate code for a patient with a history of tobacco dependence, in remission, is Z87.891. Therefore, the correct coding sequence would be E11.65, E11.22, Z87.891. This sequence accurately reflects the patient’s current conditions and relevant history, adhering to the principle of coding the most significant condition first, followed by complications and then relevant history. This approach ensures comprehensive and accurate medical record documentation for billing and statistical purposes, aligning with the rigorous standards expected at Certified Family Practice Coder (CFPC) University. Understanding the hierarchical nature of coding and the use of Z codes for historical conditions is fundamental to proficient medical coding practice.

The scenario presented involves a patient with a history of chronic obstructive pulmonary disease (COPD) who presents with an acute exacerbation. The physician’s documentation notes the exacerbation is due to a bacterial infection. According to ICD-10-CM coding guidelines, when an exacerbation of a chronic condition is due to an infection, the underlying chronic condition should be sequenced first, followed by the code for the specific infection. In this case, the chronic condition is COPD, and the exacerbation is specified as being due to a bacterial infection. Therefore, the principal diagnosis would be the COPD exacerbation, and a secondary diagnosis would be the bacterial infection. The specific ICD-10-CM code for COPD exacerbation, when due to a bacterial infection, requires identifying the appropriate code for COPD with exacerbation and then linking it to the causative organism if specified. Given the options, the most accurate coding sequence would reflect the underlying chronic condition and its exacerbation, followed by the identified infectious agent. The correct approach involves identifying the primary reason for the encounter, which is the exacerbation of COPD, and then coding the underlying condition and the specific cause of the exacerbation. The ICD-10-CM Official Guidelines for Coding and Reporting provide specific instructions for coding exacerbations of chronic conditions, emphasizing the importance of capturing both the chronic disease and the acute event. For example, if the documentation clearly states “COPD with acute exacerbation due to bacterial pneumonia,” the coding would reflect both elements. The selection of the correct code requires careful review of the physician’s documentation to ensure all qualifying conditions and their causal relationships are accurately represented, aligning with the principles of accurate and compliant medical coding as taught at Certified Family Practice Coder (CFPC) University.

The scenario describes a patient presenting with symptoms indicative of an acute exacerbation of chronic obstructive pulmonary disease (COPD). The physician’s documentation notes the presence of increased dyspnea, productive cough with purulent sputum, and wheezing, consistent with a lower respiratory infection exacerbating the underlying COPD. The physician also performed a physical examination, including auscultation of the lungs, and ordered diagnostic tests such as a chest X-ray and arterial blood gas (ABG) analysis. The ABG results show hypoxemia and hypercapnia, confirming respiratory compromise. The physician’s plan includes initiating bronchodilator therapy, a corticosteroid, and an antibiotic, along with oxygen therapy. To accurately code this encounter for Certified Family Practice Coder (CFPC) University’s rigorous curriculum, one must consider the principal diagnosis and any secondary conditions that affect patient care. The primary reason for the encounter is the acute exacerbation of COPD. ICD-10-CM coding guidelines dictate that when a patient with a known chronic condition presents with an exacerbation, the exacerbation is coded as the principal diagnosis, followed by the code for the underlying chronic condition. In this case, the patient has a pre-existing diagnosis of COPD, which is documented. The acute exacerbation is the immediate cause of the current medical services. Therefore, the coding should reflect this. The appropriate ICD-10-CM code for an acute exacerbation of COPD, not specified as with or without exacerbation, is J44.1 (Chronic obstructive pulmonary disease with (acute) exacerbation). The underlying chronic condition, COPD, is implicitly addressed by this code. If the documentation had specified the type of COPD (e.g., emphysema or chronic bronchitis), a more specific code might be applicable, but J44.1 is the most accurate for the presented information. Furthermore, the documentation supports the medical necessity for the treatments provided, including the antibiotic and corticosteroid, which are standard for managing such exacerbations. The diagnostic tests ordered are also appropriate for evaluating the severity of the exacerbation.

The scenario describes a patient presenting with symptoms indicative of a urinary tract infection (UTI) and a concurrent diagnosis of type 2 diabetes mellitus. The physician performs a comprehensive history and physical examination, orders urinalysis and urine culture, and initiates antibiotic therapy. The patient also receives counseling on diabetes management. To accurately code this encounter for Certified Family Practice Coder (CFPC) University standards, we must consider the ICD-10-CM coding guidelines for multiple conditions and the CPT coding for the services rendered. For ICD-10-CM, the primary reason for the encounter is the UTI. The specific code for a UTI, not elsewhere classified, is N39.0. The patient’s type 2 diabetes mellitus is a co-existing condition that influences the patient’s care and management, and therefore should also be coded. The appropriate ICD-10-CM code for type 2 diabetes mellitus without complications is E11.9. According to ICD-10-CM Official Guidelines for Coding and Reporting, when a patient has diabetes and a condition that is commonly associated with diabetes, the diabetes code should be listed first, followed by the code for the associated condition, if a causal relationship is stated or implied. However, in this case, the UTI is the primary reason for the visit, and the diabetes is a co-morbidity. The guidelines also state that if a patient is seen for a condition that is not related to their diabetes, the condition should be coded first, and then the diabetes. Given the presentation, the UTI is the acute issue driving the visit, and the diabetes is a chronic condition. Therefore, N39.0 should be sequenced first, followed by E11.9. For CPT coding, the physician performed a comprehensive history and physical, ordered diagnostic tests (urinalysis and urine culture), and provided counseling. The level of E/M service would be determined by the physician’s documentation of medical decision making (MDM) or time spent. Assuming the physician’s documentation supports a moderate level of MDM and the encounter involved counseling that constituted more than half of the physician’s time, a code from the 99213-99215 range (for established patient office visit) might be appropriate. The urinalysis would be coded with 81000 (Urinalysis, automated, with microscopy), and the urine culture with 87086 (Culture, bacterial; urine, with isolation and preliminary identification of each urine isolate). The question asks for the most appropriate ICD-10-CM codes to report for this encounter, reflecting the principles taught at Certified Family Practice Coder (CFPC) University, which emphasize accurate sequencing and the capture of all relevant diagnoses. The correct sequencing prioritizes the acute condition for which the patient is seeking care, while also capturing significant co-morbidities that impact management. The correct ICD-10-CM codes, sequenced appropriately, are N39.0 for the UTI and E11.9 for the type 2 diabetes mellitus.

The scenario describes a patient presenting with symptoms of a urinary tract infection (UTI). The physician performs a urinalysis and a urine culture and sensitivity (C&S) test. The urinalysis is a diagnostic test to identify the presence of bacteria, white blood cells, and other indicators of infection. The urine culture and sensitivity test identifies the specific bacteria causing the infection and determines which antibiotics are effective against it. In the context of ICD-10-CM coding, the primary diagnosis for a UTI is typically coded using a category within N39.0 (Urinary tract infection, site not specified). However, the physician’s documentation also indicates that a urine culture and sensitivity was performed. This diagnostic procedure is separately reportable using CPT codes. The appropriate CPT code for a urine culture and sensitivity test is 87086. This code specifically covers the laboratory procedure of culturing a specimen for microorganisms and performing susceptibility testing. When coding for a patient encounter, it is crucial to accurately reflect both the diagnosis and the services rendered. Therefore, the correct coding would involve assigning the ICD-10-CM code for the UTI and the CPT code for the urine culture and sensitivity. The question asks for the most appropriate *additional* code to report alongside the diagnosis of UTI, implying that the diagnosis code is already established. Therefore, the focus is on identifying the correct procedure code for the laboratory service. The CPT code 87086 accurately represents the performance of a urine culture and sensitivity test, which is a key diagnostic component of managing a UTI. Other CPT codes, such as those for urinalysis (e.g., 81000-81003) or more complex microbiological procedures, are not as specific to the described diagnostic pathway.

The scenario describes a patient presenting with symptoms indicative of an acute exacerbation of chronic obstructive pulmonary disease (COPD) and a concurrent urinary tract infection (UTI). The physician’s documentation notes “acute exacerbation of COPD, unspecified” and “cystitis due to organism, unspecified.” For the COPD exacerbation, the ICD-10-CM coding guidelines direct coders to first identify the underlying chronic condition. In this case, it is COPD. The documentation specifies “unspecified” for the exacerbation. Therefore, the appropriate code for the acute exacerbation of COPD, unspecified, is J44.1 (Chronic obstructive pulmonary disease with (acute) exacerbation, unspecified). For the UTI, the documentation specifies “cystitis due to organism, unspecified.” The ICD-10-CM index leads to N30.00 (Cystitis without hematuria) for cystitis. Since the organism is unspecified, N30.00 is the correct code. When coding multiple conditions, the sequencing of codes is crucial. The principal diagnosis is the condition chiefly responsible for the admission. In this case, the acute exacerbation of COPD is the primary reason for the patient’s presentation and admission, as it is the more severe and acute condition requiring immediate management. The UTI, while present, is secondary to the COPD exacerbation in terms of the immediate reason for care. Therefore, J44.1 should be sequenced first, followed by N30.00. The question asks for the correct sequence of ICD-10-CM codes. Based on the analysis, the correct sequence is J44.1 followed by N30.00. This reflects the principal diagnosis of the COPD exacerbation and the secondary diagnosis of the UTI. This sequencing aligns with the principle of identifying the condition that occasioned the admission.

The scenario describes a patient presenting with symptoms consistent with a urinary tract infection (UTI) and a concurrent diagnosis of type 2 diabetes mellitus. The physician performs a comprehensive history and physical examination, orders urinalysis and urine culture, and initiates antibiotic therapy. The patient also receives counseling on diabetes management and lifestyle modifications. To accurately code this encounter for Certified Family Practice Coder (CFPC) University standards, a coder must consider the principal diagnosis, secondary diagnoses, and the appropriate Evaluation and Management (E/M) code. The UTI is the primary reason for the encounter, as evidenced by the patient’s presenting symptoms and the diagnostic workup. Therefore, the ICD-10-CM code for the UTI should be sequenced first. The type 2 diabetes mellitus is a coexisting condition that influences patient care and management, requiring a secondary diagnosis code. The E/M coding requires an assessment of the medical decision making (MDM) or time spent. Given the multiple diagnoses, ordering of diagnostic tests (urinalysis, urine culture), and prescription of medication, the MDM level would likely be moderate to high. The counseling provided also contributes to the complexity. Without specific documentation details on the number of diagnoses, risk of complications, and management options considered, a precise E/M code cannot be definitively determined solely from the provided narrative. However, the question asks for the most appropriate *coding approach* considering the information. The correct approach involves identifying the principal diagnosis (UTI), sequencing the secondary diagnosis (diabetes), and selecting an E/M code that reflects the complexity of the encounter, considering both MDM and time. The use of appropriate modifiers for any procedures or services performed would also be necessary, though not explicitly detailed in the scenario for selection. The focus here is on the diagnostic coding and the general principles of E/M coding in a family practice setting, aligning with CFPC University’s emphasis on comprehensive patient care documentation.

The scenario describes a patient presenting with symptoms consistent with a urinary tract infection (UTI). The physician performs a urinalysis and a urine culture with sensitivity. The urinalysis reveals leukocytes and nitrites, indicative of infection. The urine culture identifies *Escherichia coli* (E. coli) as the causative agent, and the sensitivity testing shows it is susceptible to nitrofurantoin and resistant to ampicillin. For coding purposes, the primary diagnosis is a UTI. ICD-10-CM code N39.0 (Urinary tract infection, site not specified) is appropriate as the specific site of the UTI is not further detailed in the initial presentation. The physician’s encounter is for the management of this UTI. Evaluation and Management (E/M) coding depends on the level of service provided, which is not detailed enough to assign a specific E/M code without further information on medical decision making or time spent. However, the question focuses on the diagnostic procedures. The urinalysis is a laboratory test. CPT code 81001 (Urinalysis, automated, with microscopy and positive reagent strips or dip stick, any quantity) is often used for a comprehensive automated urinalysis. The urine culture with sensitivity is also a laboratory procedure. CPT code 87086 (Culture, bacterial; urine, with isolation, identification, and antimicrobial susceptibility studies; qualitative or semiquantitative, per specimen) accurately reflects the services performed. Therefore, the correct coding for the diagnostic procedures performed, based on the information provided, would include the urinalysis and the urine culture with sensitivity. The question asks for the most appropriate coding for the diagnostic workup.

The scenario describes a patient presenting with symptoms consistent with a urinary tract infection (UTI) and a concurrent diagnosis of type 2 diabetes mellitus. The physician performs a urinalysis and urine culture, which confirm the UTI. The physician also documents the management of the diabetes. To accurately code this encounter for Certified Family Practice Coder (CFPC) University standards, one must consider the ICD-10-CM coding guidelines for multiple conditions and the sequencing of diagnoses. The primary reason for the encounter is the UTI, which is a new condition requiring active management. The diabetes, while a chronic condition, is also being managed during this visit, indicating its relevance to the current encounter. According to ICD-10-CM Official Guidelines for Coding and Reporting, when a patient has a condition that is affected by another condition, the condition that is treated or managed for that encounter should be sequenced first. In this case, the UTI is the acute condition driving the visit and requiring specific treatment (antibiotics). The diabetes, while chronic, is also being addressed, but the UTI is the more immediate concern. Therefore, the UTI should be sequenced as the principal diagnosis. The appropriate ICD-10-CM code for a confirmed UTI is N39.0 (Urinary tract infection, site not specified). The diabetes mellitus, type 2, is also documented and managed, so it should be coded as a secondary diagnosis. The ICD-10-CM code for type 2 diabetes mellitus is E11.9 (Type 2 diabetes mellitus without complications). The question asks for the correct sequencing of diagnoses. The UTI is the primary reason for the visit and the focus of the current management. The diabetes is a co-existing condition that is also being managed. Thus, the UTI should be listed first. The correct coding sequence is N39.0 followed by E11.9.

The scenario describes a patient presenting with symptoms of a urinary tract infection (UTI) and a concurrent diagnosis of type 2 diabetes mellitus. The physician performs a comprehensive history, detailed physical examination, and orders laboratory tests, including a urinalysis and a blood glucose level. The physician also counsels the patient on managing their diabetes and the importance of hydration for the UTI. To accurately code this encounter for Certified Family Practice Coder (CFPC) University’s rigorous curriculum, we must consider the ICD-10-CM coding guidelines for multiple conditions and the CPT coding for the services rendered. For ICD-10-CM, the primary diagnosis is the condition that occasioned the visit, which in this case is the UTI. The specific code for a UTI, unspecified, is N39.0. The patient’s type 2 diabetes mellitus with hyperglycemia is a co-existing condition that influences care and requires a secondary code. The appropriate ICD-10-CM code for type 2 diabetes mellitus with hyperglycemia is E11.65. According to ICD-10-CM Official Guidelines for Coding and Reporting, when a patient has diabetes and a condition that is possibly related to the diabetes, the physician must document the relationship. In this scenario, the physician is managing both conditions, and the documentation supports the presence of both. The guidelines also state to code the condition that is treated first, or the condition that is the primary reason for the encounter. While both are present, the UTI is the acute issue prompting the visit. However, the diabetes management is also a significant part of the encounter. The most appropriate sequencing would place the UTI as the first listed diagnosis, followed by the diabetes with hyperglycemia, as the UTI is the presenting problem. For CPT coding, the encounter involves a detailed history, a comprehensive physical exam, and medical decision-making that includes ordering tests and counseling. This aligns with an Evaluation and Management (E/M) service. Given the complexity and the physician’s actions, this would likely be coded as a new patient office visit or an established patient office visit, depending on the patient’s history with the practice. Assuming this is an established patient, the level of service would be determined by the medical decision making (MDM) or time spent. The MDM components considered are the number and complexity of problems addressed, the amount and/or complexity of data to be reviewed and analyzed, and the risk of complications and/or mortality of patient management. Here, there are two stable chronic conditions (diabetes) and an acute uncomplicated illness (UTI), requiring review of lab data and moderate risk. This would typically fall into a moderate level of MDM. The physician also provided counseling, which contributes to the time spent. Based on these factors, a level 4 or 5 E/M code would be appropriate. For the purpose of this question, let’s consider the scenario as meeting the criteria for a 99214 (Office or other outpatient visit for the evaluation and management of an established patient, which requires a medically appropriate history and/or examination and moderate level of medical decision making). Therefore, the correct coding combination reflects both the UTI and the diabetes with hyperglycemia, along with the appropriate E/M service. The ICD-10-CM codes are N39.0 and E11.65, and the CPT code is 99214.

The scenario describes a patient presenting with symptoms of a urinary tract infection (UTI) and a concurrent diagnosis of type 2 diabetes mellitus. The physician performs a comprehensive history and physical examination, orders urinalysis and urine culture, and initiates antibiotic therapy. The physician also counsels the patient on diabetes management and UTI prevention. To accurately code this encounter for Certified Family Practice Coder (CFPC) University standards, we must identify the principal diagnosis and any secondary diagnoses that affect patient care, treatment, or management. The patient’s primary reason for the visit is the UTI symptoms. The diabetes mellitus is a pre-existing condition that influences the management of the UTI, as diabetic patients are at higher risk for complications from infections. According to ICD-10-CM Official Guidelines for Coding and Reporting, when a patient has a condition that is affected by another condition, and that other condition is not the reason for the encounter, the condition that is the focus of treatment is sequenced first. In this case, the UTI is the focus of the current encounter and treatment. The diabetes mellitus, while important for overall patient management, is not the primary reason for this specific visit. Therefore, the UTI code should be listed first. The ICD-10-CM code for a typical UTI, such as cystitis without hematuria, is N39.0. The ICD-10-CM code for type 2 diabetes mellitus with hyperglycemia is E11.65. Since the diabetes is a co-morbidity that impacts the management of the UTI, it should be reported as a secondary diagnosis. The guidelines also state that if a patient is admitted to an inpatient setting for a condition, and other conditions are present that do not affect the patient’s treatment or management, they are coded as secondary diagnoses. While this is an outpatient setting, the principle of reporting the primary reason for the encounter first, followed by relevant co-morbidities, remains. Therefore, the correct coding sequence would be N39.0 followed by E11.65. This reflects the physician’s focus on treating the acute UTI while acknowledging the underlying chronic condition that influences the patient’s health and treatment plan, aligning with the comprehensive approach to patient care emphasized at Certified Family Practice Coder (CFPC) University.

The scenario describes a patient presenting with symptoms indicative of a urinary tract infection. The physician performs a urinalysis and a urine culture with sensitivity. The urinalysis reveals leukocytes and nitrites, consistent with infection. The urine culture identifies *Escherichia coli* as the causative agent, and the sensitivity testing indicates resistance to ampicillin but susceptibility to nitrofurantoin and trimethoprim-sulfamethoxazole. For coding purposes, the primary diagnosis is a urinary tract infection. ICD-10-CM code N39.0 (Urinary tract infection, site not specified) is appropriate given the information provided. The physician’s encounter is for the evaluation and management of this condition. Assuming this is a new patient visit or a significant problem requiring a new or expanded history, examination, and medical decision-making, a moderate level of complexity would be assigned. For example, if the physician documented a comprehensive history, a detailed examination, and moderate complexity medical decision-making, CPT code 99204 (Office or other outpatient visit for the evaluation and management of a new patient, which requires these three key components: a comprehensive history; a comprehensive examination; medical decision making of moderate complexity) or 99214 (Office or other outpatient visit for the evaluation and management of an established patient, which requires at least two of these three key components: a problem-focused history; a problem-focused examination; medical decision making of moderate complexity) would be considered, depending on the patient’s established status. However, the question focuses on the diagnostic procedures. The urinalysis is a laboratory procedure. CPT code 81001 (Urinalysis, automated, with microscopy and positive reagent strip(s) or dip stick, all of the following dip stick parameters: leukocytes, protein, glucose, ketones, specific gravity, pH, blood, urobilinogen, bilirubin, and nitrite) is appropriate for an automated urinalysis with microscopy and reagent strip analysis. The urine culture with identification and sensitivity testing is also a laboratory procedure. CPT code 87088 (Culture, bacterial; with isolation, identification, and antimicrobial susceptibility testing of isolates from urine only) accurately reflects the services performed. Therefore, the correct coding sequence for the diagnostic procedures would include the urinalysis and the urine culture with sensitivity.

The scenario describes a patient presenting with symptoms that could be attributed to multiple conditions, requiring the coder to determine the most accurate and specific ICD-10-CM code. The patient has a history of type 2 diabetes mellitus, currently managed with oral medication. They present with new onset of bilateral foot pain, specifically described as burning and tingling, which are classic symptoms of diabetic neuropathy. The physician’s documentation notes “diabetic neuropathy affecting bilateral lower extremities.” To arrive at the correct code, the coder must first identify the primary condition being treated and documented. In this case, it is diabetic neuropathy. Then, they must locate the appropriate ICD-10-CM code for this condition. Following the ICD-10-CM Alphabetic Index, one would look up “Neuropathy, diabetic.” This leads to a reference for “diabetes with nervous system complications.” Further exploration within the Tabular List under category E11 (Type 2 diabetes mellitus) reveals subcategories for complications. Specifically, E11.40 (Type 2 diabetes mellitus with unspecified neuropathy) and E11.42 (Type 2 diabetes mellitus with diabetic peripheral neuropathy) are relevant. Given the description of burning and tingling in the bilateral lower extremities, “peripheral neuropathy” is a more specific and accurate descriptor than “unspecified neuropathy.” Therefore, E11.42 is the most appropriate code. The documentation explicitly states “diabetic neuropathy affecting bilateral lower extremities,” which aligns perfectly with the definition of E11.42. The presence of type 2 diabetes mellitus is already incorporated into the E11 category. No external cause codes are indicated as the neuropathy is a manifestation of the diabetes itself.

The scenario describes a patient presenting with symptoms indicative of a urinary tract infection (UTI). The physician performs a urinalysis and a urine culture and sensitivity (C&S) test. The urinalysis is a diagnostic test to identify the presence of bacteria, white blood cells, and other indicators of infection. The urine C&S is a more definitive test that not only identifies the specific bacteria causing the infection but also determines which antibiotics are effective against it. For accurate coding, the coder must identify the most specific diagnosis code for the confirmed UTI and then select the appropriate CPT codes for the diagnostic procedures performed. The patient is diagnosed with a bacterial UTI. The urinalysis is reported with CPT code 81001 (Urinalysis, automated, with microscopy and manual differential, any number of reported findings). The urine culture and sensitivity, which identified *Escherichia coli* and determined its susceptibility to nitrofurantoin, is reported with CPT code 87088 (Culture, bacterial; with isolation, identification, and antimicrobial susceptibility testing of isolates from urine, via automated method). The diagnosis of bacterial UTI, specifically caused by *E. coli*, would be coded using ICD-10-CM code N39.0 (Urinary tract infection, site not specified). However, given the identification of the causative organism, a more specific code is available. The presence of *E. coli* as the causative agent points to a more precise diagnosis. While N39.0 is a general code for UTI, the documentation supports a more specific etiology. The most appropriate ICD-10-CM code reflecting a UTI due to a specified organism, if available and documented, would be preferred. In this case, the documentation specifies *E. coli*. Therefore, the coder must select the ICD-10-CM code that accurately reflects this. The correct ICD-10-CM code for a UTI due to *E. coli* is not directly available as a single code that combines both UTI and *E. coli*. However, the guidelines for coding infections state to code the infection and then, if applicable, the causative organism. For UTIs, N39.0 is the primary code. If the organism is specified, additional codes might be used in conjunction, or a more specific code might exist if the organism is commonly associated with a particular type of UTI. Reviewing the ICD-10-CM index, under “Infection, urinary tract,” it directs to N39.0. Under “Escherichia,” it lists various conditions. However, for a UTI specifically caused by *E. coli*, the most accurate approach is to code the UTI and then, if the documentation supports it, consider if there’s a more specific code for *E. coli* infections of the urinary tract. In the absence of a single code that explicitly states “UTI due to *E. coli*,” N39.0 remains the primary diagnosis for the UTI. The CPT codes 81001 and 87088 accurately represent the diagnostic procedures. Therefore, the combination of N39.0 for the diagnosis and the specified CPT codes for the services is the correct coding. The explanation focuses on the correct ICD-10-CM code for the diagnosis and the appropriate CPT codes for the services rendered, aligning with the principles of accurate medical coding taught at Certified Family Practice Coder (CFPC) University. Understanding the specificity of ICD-10-CM codes and the correct application of CPT codes for laboratory procedures is fundamental to the curriculum. The scenario tests the ability to translate clinical documentation into accurate codes, a core competency for any certified coder, especially within the context of family practice where common infections like UTIs are frequently encountered. The emphasis is on selecting the most precise codes based on the provided clinical information, reflecting the university’s commitment to rigorous academic standards in medical coding education.