Medical Coding

Which of the following are characteristics of the index for the ICD-10-CM?

The main term represents the diseases, conditions, nouns, and adjectives that you might see in the patient record.

The main term is the first place you go to locate the code for the patient's disease or condition.

Subterms or essential modifiers are located beneath the main term.

All of the above

All the above

Which of the following statements about coding in ICD-10-CM is most correct?

Coders are not allowed to assign codes directly from the index without obtaining physician confirmation.

It is an acceptable practice for coders to both reference and code directly from the index.

It is not acceptable for coders to both reference and code directly from the index.

None of the above

It is not acceptable for coders to both reference and code directly from the index.

Which of the following statements about coding guidelines is most correct?

Coding for inpatient and outpatient services uses the same coding guidelines.

Coding for inpatient and outpatient services uses coding guidelines are interchangeable, so it's acceptable to only memorize one set of codes.

Coding for inpatient and outpatient services uses different coding guidelines.

None of the above

Coding for inpatient and outpatient services uses different coding guidelines.

A combination code is a single code used to classify: ____________, or a diagnosis with an associated secondary process (manifestation), or a diagnosis with an associated complication.

additional codes

multiple codes

subterm entries

two diagnoses

two diagnoses

To accurately code, it's necessary for you to have in-depth knowledge of medical terminology, anatomy and physiology, disease conditions, and pharmacology, along with an understanding of the __________ coding guidelines format and conventions.

AAPC's Medical Coding Code of Ethics

diagnosis

Medicare Catastrophic Coverage Act

ICD-10-CM

ICD-10-CM

There are ___ steps to accurate coding.

4

2

8

18

8

HIPAA stands for __________.

Health Insurance Portability and Availability Act

Health Insurance Potential and Availability Act

Health Insurance Portability and Accountability Act

Health Insurance Potential and Accountability Act

Health Insurance Portability and Accountability Act

The main or highest level of organization in the ICD-10-CM is the ______________.

Chapter

Body system

Disease state

Section

Chapter

______________________________ hypertension is when the patient takes medication that successfully manages the problem; _____________________ hypertension is due to an underlying condition. Code the underlying condition ____________________.

Controlled; secondary; first

Secondary; transient; second

Controlled; transient; second

Essential; secondary; first

Controlled, Secondary, First

Z codes are used to __________________________________.

indicate that a person with a resolving condition is being seen for specific aftercare, such as removal of stitches

indicated that a person is being seen for the sole purpose of special therapy, such as chemotherapy

indicate that a person who is not ill is being seen for a specific reason, such as for a pre-employment examination

All of these are indicated with Z codes

all of these are indicated with Z codes

Mr. Solomon is diagnosed with a viral intestinal infection. The notes have no other information. What is the correct code for his condition?

This condition cannot be coded without more information.

A08.4

K63.89

K63.9

A08.4

An established patient, Ms. Parker, is a type II diabetic, complaining of painful urination and increased frequency. Her lab results confirm a urinary tract infection, and show blood glucose levels within normal limits. What is/are the first-listed diagnosis term(s)?

Diabetes

Painful urination

Type II Diabetes

Urinary Tract Infection

Urinary Tract Infection

Mrs. Potter is diagnosed with rheumatoid arthritis. There are no other characteristics in the physician's notes. What is the correct ICD-10-CM code for her condition?

M06

M06.9

M06.01

M06.00

M06.9

Mrs. Lee is seen for acute and chronic laryngitis. What is/are the correct code(s) for her condition?

J04.0 and J37.0

J04.0 only

B95.0

B95.9

J04.0 and J37.0

An external cause code is ______________________________________.

often used as the first-listed diagnosis in special cases

used to provide more information and to complete the patient's medical story

does not include information about the details of an accident or injury, such as if the accident occurred in a boat vs. a car

are no longer used in ICD-10-CM coding because of the time required for the provider

used to provide more information and to complete the patient's medical story

Ms. Gregory is admitted with uncontrolled nausea, with vomiting, after chemotherapy for lung cancer. What is the correct ICD-10-CM code for the first-listed diagnosis?

R11.2

R11.1

R11.12

C46.5

R11.2

The ICD-10-CM main manual contains which of the following indexes?

Numerical Index

Code Index

Diagnosis Index

Tabular Index

Tabular Index

When separate codes exist to identify acute and chronic conditions, the ______ code is sequenced first.

chronic

acute

neither, you leave the code blank

none of the above

acute

As a medical coder, it is your responsibility to ensure that the data reported are as accurate as possible, not only for classification and study purposes but also to obtain appropriate ____________.

billing

coverage

records

reimbursement

Reimbursement

The largest third-party payer in the United States is ________________.

Medicare

private insurance carriers

the consumer

the Department of Health and Human Services

Medicare

There are four groups whose function it is to deal with in-depth coding principles and practices: ________________________, National Center for Health Statistics, American Health Information Management Association, and American Hospital Association.

Centers for Medicare and Medicaid Services

Department of Health and Human Services

Health Care Financing Administrations

AAPC

Centers for Medicare and Medicaid Services

The Medicare program consists of which of the following?

Part A, Hospital Insurance

Part B, Supplemental Medical Insurance

Both Part A & Part B

None of these are included

Both Part A & Part B

HIPAA has privacy requirements that govern the disclosure of patient ____________ placed in the medical record by physicians, nurses, and other healthcare providers.

conditions

personal details

protected health information (PHI)

notes

Protected health information (PHI)

Which characteristic of a diagnosis is important in ICD-10-CM if it is a characteristic of the condition?

Specificity

Whether the condition is acute or chronic

Laterality

All of the above

All the above

The term sequela refers to __________________________.

the acute phase of an illness or injury

the chronic phase of an illness

a less serious form of an illness or injury

a condition produced after the acute phase of an illness or injury

a condition produced after the acute phase of an illness or injury

The complexity of medical decision making (MDM) is based on several elements, including: number of diagnoses or management options, amount and/or complexity of data to review, and ________________.

risk of complications or death if the condition goes untreated

Ms. Lurie received anesthesia during surgery. She was not expected to survive without the surgical procedure being performed. Which physical status modifier should be added to the anesthesia code?

-P5

Current Procedural Terminology (CPT) is a coding system developed by the American Medical Association (AMA) to convert widely accepted, uniform descriptions of medical, surgical, and diagnostic services into ____-digit numeric codes.

five

Modifiers inform third-party payers of circumstances that may affect the way __________ is determined.

payment

Dr. Franklin acted as the surgical assistant to Dr. Edwards during Mr. Cook's surgery for repair of an inguinal hernia. Dr. Franklin's services would be reported using which of the following modifiers?

-81

J-codes refer to which of the following?

refer to non-orally administered medication and chemotherapy drugs

The Anesthesia section of the CPT manual is divided first by _________.

anatomicsite

Delia, a four-year-old, established patient is seen by Dr. Marcus for mild pain in her left ear, of 2-days duration. Dr. Marcus diagnosed a minor infection and prescribed antibiotics for acute exudative otitis media. The correct level of presenting problem in Delia's case would be ______.

self-limited

Unlisted codes _______ procedures for which there is not a more specific code.

none of the above

The global surgery period includes all ______________.

routine post-operative care

The level of E/M service is based on documentation, key components, and ________________.

contributing factors

Incorrect coding can result in which of the following?

all the above

When time is calculated for anesthesia services, time begins when ______________.

the anesthesiologist starts preparing the patients for anesthesia

Which CPT modifier describes a procedure that was reduced at the direction of the physician?

-52

A triangle placed in front of a code indicates which of the following?

that the description for the code has been changed or modified since the previous edition

CPT code ________ is used to report materials and supplies by the physician for which no other more specific CPT code exists.

99070

Level II National Codes (HCPCS) are alphanumeric codes used by providers to report _________ provided to Medicare or Medicaid patients for which no CPT codes exist.

services, supplies, and equiment

Ms. Cane underwent an outpatient procedure which required the use of anesthesia. The anesthetic she received allowed her to undergo the procedure without pain, although she was not completely asleep. What type of anesthesia did Ms. Cane receive?

Conscious/moderat

Anesthesia services include which of the following?

preoperative visits to the patient by the anesthesiologist

postoperative visits to the patient by the anesthesiologist

anesthesia during the procedure

none of the above

all the above

Which of the following is correct procedure when there are multiple CPT modifiers assigned to one code?

list the modifiers from the highest to the lowest

Which of the following CPT codes is used to report routine postoperative care?

99121

99122

99123

none of the above

None of the above

Which of the following is the incorrect definition of the anesthesia code it is matched with?

P4: Pre-morbid condition with high risk of demise unless procedural intervention is performed.

Dr. Williams has been treating an elderly patient, Mr. Cook, for hernia. During the global period for his hernia treatment, Dr. Williams was forced to admit Mr. Cook to a skilled nursing facility when he became combative because of advanced dementia due to Alzheimer's disease. What CPT modifier would be added to Mr. Cook's admission service?

-24

The correct CPT anesthesia code for repair of cleft palate is _____.

00172

When the words "separate procedure" appear after the descriptor of a code, you know which of the following?

the procedure was a minor procedure that would only be reported if it was the only service provided

Mr. Douglas underwent a procedure for implantation of a patient-activated cardiac event recorder. What is the correct CPT code for Mr. Douglas' procedure?

33282

Endoscopic procedures are reported based on which of the following?

the farthest place to which the scope is advanced

Skin traction involves the use of which of the following?

all the above

After destruction methods are used, there is _____ tissue remaining for pathological examination.

no

Incision and drainage codes are divided into subcategories according to which of the following?

not the size of the lesion

Local anesthesia is defined in the CPT guidelines as which of the following?

all the above

Alex, a 2-year-old, is fitted with an external fixation device of the head due to a congenital disorder. This device is also known as a ___________.

cranial halo

__________ determines the contents of a surgical package.

third party payers

Dr. Miller performs a simple repair for a 4.3 cm arm wound and an intermediate repair for a 2.8 cm scalp wound. What are the correct CPT codes for these repairs?

12032, 12002-51

Repaired wounds are measured in ___________.

centimeters

In order to correctly report coronary bypass grafts, medical coders must know which of the following?

the anatomical site the vessel being grafted came from

________ is responsible for the manufacture of most blood cells within the body.

bone marrow

A type of graft taken from the upper thigh of the patient is known as a ____________.

fascia lata

Mr. Richards undergoes a diagnostic endoscopic procedure. His procedure should only be reported if:

no surgical procedure was performed during the same operative session

Fracture codes are based on which of the following?

not fracture type

Which of the following codes reports a coronary artery bypass using a saphenous vein graft?

33510

The code for the incision and drainage of a nasal abscess using an external approach to the abscess is found in the _______ subsection of the CPT Surgery section.

Integumentary

The __________ includes typical follow-up care.

surgical package

The CPT Surgery section is organized first by _________.

body system

CPT code ________ is used to report materials and supplies by the physician for which no other more specific CPT code exists.

99070

To correctly code for local treatment of burns, you need to know the percentage of body surface and _____________.

depth of burn

For multiple therapeutic procedures performed through a scope during the same operative session, you should report which of the following?

NOT only the major (most extensive) procedure

A medical coder must do which of the following before using codes from the wound exploration category?

assess the extent of the required procedure

Packing, ligation, and _______ are all methods physicians use to control nosebleeds.

cauterization

The correct CPT code for placing a nasogastric tube using fluoroscopic guidance is ______.

43752

All codes reported for procedures from the Eye and Ocular Adnexa subsection are which of the following?

NOT unilateral

The correct CPT code for a curettage performed after vaginal delivery is __________.

NOT 58120

A shunt is used to _________.

relieve pressure in the brain caused by fluid build-up

The code for a diagnostic colonoscopy includes which of the following services?

all the above

Derek undergoes a procedure to remove a superficial foreign body from his external left eye. What is the correct CPT code for this procedure?

60240

Which of the following is the correct code for reporting removal of the entire thyroid?

65205-LT

The correct CPT code for a radical retro-pubic prostatectomy with nerve sparing is __________.

40702

CPT code ________ is used to report repair of a cleft lip/nasal deformity primary bilateral, one of two stages.

55840

A colpotomy is a procedure where an incision is made into the __________.

vagina

The Urinary subsection of the CPT Surgery section is arranged, first, by:

anatomical site

Artificial insemination performed via intrauterine is reported using which code?

NOT 58321

The correct code for an excision of a sclera lesion from the left eye is _______.

66130

CPT code ________ is used to report a diagnostic esophagoscopy, during which an esophageal polyp was found and removed by hot biopsy forceps.

43216

Miss Hansen undergoes a colposcopy of the vulva with biopsy. The correct CPT code for her procedure would be __________.

56821

The correct code for removal of an IUD would be listed in the ________ category of the CPT manual.

Introduction

Within the Male Genital System, the greatest numbers of codes fall under which category?

the penis category

Which of the following is the correct code for a vasectomy?

55250

A gastrostomy tube is used for _______________.

feeding purposes

_________ is the most common neuroplastic procedure.

carpal tunnel

The services normally provided under code 59400 include antepartum care, delivery, and ________________

postpartum care

The notes under the Eye and Ocular Adnexa section specify that code __________ should not be reported in addition to codes _______ - ________

69990, 65091, 68850

The term "peripheral nervous system" refers to which of the following?

the nervous structures outside too the central nervous system

The Endocrine section of the CPT manual contains codes for how many endocrine glands?

4

In the CPT manual, which of the following statements about hysterectomy codes is correct?

Hysterectomy codes are first divided by approach and further divided based on any secondary procedures that were performed.

Codes ______ - ______ identify the serum globulins extracted from human blood or recombinant immune globulin products created in a laboratory through genetic modification of human and/or animal proteins.

90281--0399