Deck 5: Diagnostic Coding

Question 1

Diagnoses that relate to a patient's previous medical problem and that have no bearing on the patient's present condition should be __________ when coding.

A) handled according to specific insurance guidelines
B) included
C) excluded
D) disclosed

Answer 1

excluded

Question 2

In ICD-10-CM, a code with a fourth digit 9 or fifth digit 0 for diagnosis codes means

A) data in the medical record are specified.
B) information in the health record is unspecified.
C) data in the medical record show right side is affected.
D) information in the medical record shows left side is involved.

Answer 2

information in the health record is unspecified.

Question 3

Diagnostic codes on an insurance claim explain

A) the patient's condition that was treated during the visit.
B) the professional services provided during the visit.
C) the supplies that were provided to the patient.
D) the provider's identification.

Answer 3

the patient's condition that was treated during the visit.

Question 4

The diagnosis listed first in submitting insurance claims for patients seen in a physician's office is the

A) principal diagnosis.
B) primary diagnosis.
C) secondary diagnosis.
D) patient's presenting complaint.

Question 5

In locating a diagnosis, look up the main term, which is the

A) disease.
B) anatomic part.
C) injury.
D) both a and c

Question 6

What is the consequence when a medical practice does not use diagnostic codes?

A) It affects the physician's level of reimbursement for inpatient claims.
B) Claims can be denied.
C) Fines or penalties can be levied.
D) All of the above.

Question 7

Which of the following is the correct order of steps to take in ICD-10-CM coding?

A) Locate the main term in the Alphabetic Index, verify the code in the Tabular List, read any instructions in the Tabular List, check for exclusion notes, and assign the code.
B) Locate the main term in the Tabular List, verify the code in the Alphabetic Index, read any instructions in the Alphabetic Index, and assign the code.
C) Locate the diagnosis by the adjective in the Alphabetic Index, verify the code in the Tabular List, and assign the code.
D) Locate the diagnosis by the main term in the Alphabetic Index, read any instructions pertaining to the term, and assign the code.

Question 8

Why is the correct sequence of codes on an insurance claim important?

A) To make the chronology of patient care events understood.
B) To make the severity of disease understood.
C) It is not important as long as the correct indicator is used for each line of service.
D) Both a and b

Question 9

Terms enclosed in parentheses following the main term are referred to as

A) nonessential modifiers.
B) essential modifiers.
C) exclusions.
D) fifth digits.

Question 10

ICD-10-PCS used in hospital billing replaces which volume of ICD-9-CM?

A) Volume 1
B) Volume 2
C) Volume 3
D) Both Volumes 1 and 2

Question 11

Which of the following are examples of diagnosis-related procedures?

A) New patient and established patient visits
B) Imaging services and cardiovascular services
C) Local and general anesthesia
D) Histology and pathology procedures

Question 12

The first three characters of an ICD-10-CM code are composed as

A) Character 1 (alpha), Character 2 (numeric), Character 3 (numeric).
B) Character 1 (alpha character), Character 2 (alpha), Character 3 (numeric).
C) Character 1 (numeric), Character 2 (numeric), Character 3 (alpha).
D) Character 1 (numeric), Character 2 (alpha), Character 3 (alpha).

Question 13

In ICD-10-CM, a placeholder for future code expansion is shown as

A) X character.
B) O character.
C) ___ (underline symbol).
D) '?' symbol.

Question 14

Codes that are used principally by tumor or cancer registries are

A) neoplasm codes.
B) default codes.
C) morphology codes.
D) manifestation codes.

Question 15

The diagnosis obtained following review of studies for the condition that prompted inpatient hospitalization is the

A) secondary diagnosis.
B) principal diagnosis.
C) primary diagnosis.
D) procedure diagnosis.

Question 16

Combination codes are a single code used to report

A) two diagnoses.
B) a diagnosis with an associated manifestation.
C) a diagnosis with an associated complication.
D) all of the above.

Question 17

Diagnosis codes for body mass index (BMI) reported by a clinician who is not the patient's provider in the medical record must be accompanied by

A) an associated diagnosis such as obesity by the clinician.
B) an associated diagnosis such as obesity by the patient's provider.
C) the patient's weight record.
D) the attending physician's attestation of BMI with signature.

Question 18

The International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM), was published by the World Health Organization in

A) 1986.
B) 1992.
C) 2001.
D) 2009.

Question 19

Codes that describe symptoms and signs are acceptable for reporting purposes

A) any time they are documented.
B) when a definitive diagnosis has not been established.
C) if the sign or symptom is an integral part of the disease process.
D) under no circumstances.

Question 20

The sixth character of an ICD-10-CM code can signify

A) etiology.
B) anatomic site.
C) severity.
D) trimester of pregnancy.

Question 21

When reporting preoperative evaluations,

A) only the condition requiring the surgery is reported.
B) the condition requiring the surgery is reported as the primary diagnosis followed by a code from subcategory code Z01.80.
C) a code from subcategory code Z01.80 only is reported.
D) a code from subcategory code Z01.80 is reported as the primary diagnosis followed by a code describing the condition which required the surgery.

Question 22

ICD-10-CM classifies __ and __ information for statistical purposes.

Question 23

Diagnosis code Z79.4 (long-term use of insulin) is used to describe

A) the patient who routinely takes insulin.
B) the patient who has taken insulin for more than 2 years.
C) the patient who has taken insulin for more than 10 years.
D) any patient who takes insulin, even on a temporary basis.

Question 24

The common translation tool developed by the US government to translate ICD-9-CM codes to ICD-10-CM codes is referred to as the _____.

Question 25

Place of occurrence codes are reported to identify the location of the patient at the time of injury and are reported

A) only at the initial encounter for treatment of the injury.
B) at every encounter for treatment of the injury.
C) at every encounter for treatment of the injury including late effects of the injury.
D) only for residual conditions treated that relate to the initial injury.

Question 26

What is the table that contains a classification of substances for identifying poisoning states and external causes of adverse effects?

A) Table of Drugs and Chemicals
B) Table of Neoplasms
C) Table of Hypertension
D) Table of Morphology

Question 27

Which of the following is NOT a reason why medical practices have adopted computer-assisted coding?

A) Shortage of coders
B) Adoption of electronic health records
C) Constant changes in code numbers and rules
D) Future elimination of coding staff

Question 28

Carcinoma in situ is used to describe

A) metastatic cancer.
B) a secondary tumor.
C) cancer that is confined to the site of origin.
D) none of the above.

Question 29

A principal diagnosis is only applicable to the ___ place of service.

Question 30

A working knowledge of _______________ and a course in anatomy and physiology are essential to becoming a top-notch coder of diagnoses.

Question 31

External cause codes are used

A) when a person who is not currently sick encounters health services for some specific purpose.
B) to show cause of injury.
C) to code neoplasms.
D) to code hypertension.

Question 32

A patient is being evaluated in the office for an anterior cruciate ligament (ACL) tear. Which term should NOT be used to code the diagnosis?

A) "Suspected" ACL tear
B) "Likely" ACL tear
C) "Rule out" tear
D) All of the above

Question 33

During the transition to ICD-10-CM, the ______ will determine if a claim should be reported using an ICD-9-CM code or an ICD-10-CM code.

Question 34

In what case should a Z code be used?

A) Sterilization
B) Hysterectomy
C) Antibiotic injection
D) Dermatitis

Question 35

Which statement is true regarding neoplasms?

A) They are new growths.
B) They may be malignant.
C) They may be benign.
D) All of the above.

Question 36

Patient encounters for subsequent treatment of an injury are identified with a seventh character of

A) A.
B) D.
C) S.
D) X.

Question 37

The term malignant in relation to blood pressure means

A) tumor forming.
B) cancer.
C) uncertain behavior.
D) life-threatening.

Question 38

Asymptomatic HIV infection status is reported as

A) B20.
B) B21.
C) Z11.4.
D) Z21.

Question 39

Computer software that predicts the code for a word or phrase based on usage from the past is referred to as

A) retroactive-based method.
B) statistics-based method.
C) rules-based method.
D) prediction-based method.

Question 40

When reporting obstetrical care, the trimester of pregnancy is indicated by

A) a combination code.
B) the sixth character of the Chapter 15 code.
C) the seventh character of the Chapter 15 code.
D) an additional code.

Question 41

_____ codes are only reported by the provider who is initially treating a patient for an injury.

Question 42

In type II DM, also referred to as _____, the patient's pancreas produces some insulin but the amount produced is ineffective to remove sugar from the bloodstream.

Question 43

Volume 2, the Alphabetic Index to Diseases and Injuries, is placed ____ in most coding manuals.

Question 44

Annual updates to the ICD-10-CM coding system are published in the _____, by the US Government Printing Office.

Question 45

When coding multiple injuries, the diagnosis for the conditions treated should be sequenced in the order of ____.

Question 46

Alphabetic Index entries with the acronym ____ indicate that there is no further classification of the disease in ICD-10-CM.

Question 47

Routine outpatient prenatal care is reported with a code from category ___.

Question 48

An ___ effect is a reaction to a drug that occurs when the appropriate drug is taken, using the appropriate dosage.

Question 49

When a neoplasm has been analyzed by the pathologist but has not been confirmed as benign or malignant, it would be coded from the column labeled _____.

Question 50

Burns caused by chemicals are referred to as _____ in the Official Coding Guidelines.

Question 51

A term used as the name of a disease, structure, operation, or procedure, usually derived from the name of a place or a person who discovered or described it first, is called a/an ____.

Question 52

The convention ____ used after a code indicates the need to report another code in the same sequence as indicated in the index.

Question 53

Symbols, punctuation marks, indentations, and other similar rules for determining the appropriate diagnosis code are referred to as _____.

Question 54

Certain codes that should never be reported at the same time are indicated by the convention ___.

Question 55

Assistance in coding hypertension-related diseases can be located in Chapter ___ of the Chapter Specific Coding Guidelines.

Question 56

The keyword vaccination would be an indicator that the encounter would be reported with a ___ code.

Question 57

For coding purposes, a myocardial infarction of __ weeks' duration or less is considered acute.

Question 58

ICD-10-CM codes have from ____ to ___ characters.

Question 59

ICD-10-CM codes that begin with the letter D indicate that the condition is some sort of _____.

Question 60

Always code to the highest level of ____.

Question 61

When performing a routine physical and an abnormality is found, the abnormality should be reported and sequenced _____.

Question 62

When payer guidelines indicate that a service may not be a covered benefit, based on the diagnosis reported, it is recommended that the patient sign a ____.

Question 63

A patient was diagnosed with diverticulosis and diverticulitis of the colon. List the appropriate ICD-10-CM code(s) for these conditions.

Question 64

A 67-year-old man consults the physician because of his concern over symptoms of weight loss and hemoptysis. The impression is "rule out bronchogenic carcinoma." The patient is referred to another physician for bronchoscopy. What ICD-10-CM code(s) will the office of the physician who initially examined the patient list on the insurance claim form?

Question 65

When coding for outpatient surgery, if the postoperative diagnosis is different from the preoperative diagnosis, select the ____________ as the first listed diagnosis.

Question 66

Provide the appropriate ICD-10-CM code for a cellulitis of the anus.

Question 67

List the ICD-10-CM code(s) for a patient with glaucoma with recurrent iridocyclitis.

Question 68

Where does the Alphabetic Index of the ICD-10-CM coding manual instruct the coder to go when looking up the condition leiomyosarcoma?

Question 69

List the ICD-10-CM code(s) for a patient seen in the medical facility with diabetic retinopathy (insulin-dependent, not stated as uncontrolled) with retinal detachment.

Question 70

Provide the appropriate ICD-10-CM code for eczematous dermatitis.

Question 71

Provide the appropriate ICD-10-CM code for bursitis of the elbow.

Question 72

What ICD-10-CM code would be reported on the insurance claim form for an old myocardial infarction that is healed?

Question 73

In the computer-assisted coding technology known as ___, the physician uses pull-down menus.

Question 74

When the physician makes hospital visits, code the reason for the visit, which may not necessarily be the reason the patient was admitted to the hospital.

Question 75

A patient is seen in the emergency department with arteriosclerotic cardiovascular disease with congestive heart failure. List the ICD-10-CM code(s) required for these two conditions.

Question 76

It is possible for the primary diagnosis and the principal diagnosis to be the same.

Question 77

A patient was seen for a fever of unknown origin. List the appropriate ICD-10-CM code(s) for this condition.

Question 78

Proper coding can mean financial success or failure of a medical practice.

Question 79

All diagnoses that affect the current status of the patient and are documented can be assigned a code.

Question 80

How should an insurance billing specialist list the diagnostic codes on an insurance form when a specific condition is stated as both acute and chronic?