Deck 6: General Coding Guidelines for Medical and Surgical Procedures

Question 1

____ identifies procedure codes identified by the Medicare Code Editor as procedures covered under limited circumstances.

A)Bilateral procedure
B)Nonspecific OR procedure
C)Noncovered OR procedure
D)Limited coverage

Answer 1

D

Question 2

Which of the following is a characteristic of ICD-10-PCS?

A)Codes have a decimal point
B)It is similar to ICD-10-CM codes
C)There are a limited number of codes
D)Codes are seven characters

Answer 2

D

Question 3

The third character of an ICD-10-PCS code represents ____.

A)section
B)root operation
C)qualifier
D)body system

Answer 3

B

Question 4

The sixth character of an ICD-10-PCS code represents ____.

A)device
B)root operation
C)qualifier
D)body system

Question 5

Cutting off all or a portion of the upper or lower extremities is ____.

A)destruction
B)fragmentation
C)detachment
D)resection

Question 6

Who is responsible for the maintenance of ICD-10-PCS?

A)AHIMA
B)AMA
C)NCHS
D)CMS

Question 7

In some instances,a surgical wound is not closed at the time of a surgical operation and is allowed to heal and will be closed at a later date.This would be an example of when a ____ would be coded.

A)closure
B)bilateral procedure
C)biopsy
D)limited coverage

Question 8

Freeing a body part from an abnormal physical constraint is called ____.

A)reposition
B)division
C)release
D)transfer

Question 9

The mapping files that crosswalk ICD-9-CM to ICD-10-PCS are known as ____.

A)GEMS
B)ACT
C)HIM
D)CMS

Question 10

Which of these is a true characteristic of significant procedures?

A)Surgical in nature
B)Carry a procedural risk
C)Carry an anesthetic risk
D)Require specialized training
E)All of the above

Question 11

Which of the following is a characteristic of ICD-10-PCS?

A)Codes are numeric
B)It is similar to ICD-9-CM procedure codes
C)The letters "I" and "O" are not used
D)Codes are three to four digits

Question 12

If a patient's procedure is canceled before he or she shows up at the hospital,what is the correct Z code to assign?

A)Z53.09 Surgical or other procedure not carried out because of contraindication
B)Z53.20 Surgical or other procedure not carried out because of patient's decision
C)Z53.9 Procedure not carried out for other reasons
D)None of the above

Question 13

The first character of an ICD-10-PCS code represents ____.

A)body part
B)approach
C)section
D)device

Question 14

If a surgical procedure was canceled because the patient developed atrial fibrillation before the start of the procedure,which Z code would be assigned?

A)Z53.09 Surgical or other procedure not carried out because of contraindication
B)Z53.20 Surgical or other procedure not carried out because of patient's decision
C)Z53.9 Procedure not carried out for other reasons
D)None of the above

Question 15

ICD-10-PCS is divided into how many sections?

A)7
B)10
C)14
D)16

Question 16

The fourth character of an ICD-10-PCS code represents ____.

A)body part
B)approach
C)section
D)device

Question 17

Taking or letting out fluids and/or gases from a body part is called ____.

A)extirpation
B)fragmentation
C)extraction
D)drainage

Question 18

Which of the following is a characteristic of ICD-10-PCS?

A)Codes are alphanumeric
B)They are similar to ICD-10-CM diagnosis codes
C)Number of codes is limited
D)Codes are three to four digits

Question 19

Which of the following is NOT a characteristic of ICD-10-PCS codes?

A)Codes are alphanumeric
B)Codes are seven characters
C)Codes are expandable
D)Codes are three to four digits

Question 20

Cutting out or off,without replacement,a portion of a body part is called ____.

A)resection
B)excision
C)destruction
D)extraction

Question 21

Procedures performed directly on the skin or mucous membrane and procedures performed indirectly by the application of external force through the skin or mucous membrane are called ____.

A)percutaneous
B)open
C)via natural or artificial opening
D)external

Question 22

Visually and/or manually exploring a body part is called ____.

A)creation
B)fusion
C)inspection
D)map

Question 23

If a surgical procedure starts out as a laparoscopic approach,it may never be converted to an open procedure.

Question 24

Entry,by puncture or minor incision,of instrumentation through the skin or mucous membrane and any other body layers necessary to reach the site of the procedure is called ____.

A)open
B)percutaneous
C)percutaneous endoscopic
D)open with percutaneous endoscopic assistance

Question 25

Stopping,or attempting to stop,postprocedural bleeding is called ____.

A)inspection
B)control
C)map
D)alteration

Question 26

Putting in or on biological or synthetic material that physically reinforces and/or augments the function of a portion of a body part is called ____.

A)restriction
B)insertion
C)supplement
D)revision

Question 27

The terminology used in ICD-10-PCS is such that multiple meanings can be used for the same term.

Question 28

ICD-10-PCS codes are alphanumeric.

Question 29

ICD-10-PCS is expandable with an unlimited number of codes.

Question 30

Cutting through the skin or mucous membrane and any other body layers necessary to expose the site of the procedure is ____.

A)open
B)percutaneous
C)percutaneous endoscopic
D)open with percutaneous endoscopic assistance

Question 31

Moving all or a portion of a body part to its normal location or other suitable location is called ____.

A)reposition
B)release
C)transfer
D)transplantation

Question 32

Taking out or off a device from a body part is called ____.

A)replacement
B)removal
C)revision
D)change

Question 33

It is a routine part of most surgical procedures to close the operative wound(s),so it is not necessary to code this separately.

Question 34

The abbreviation "OR" in the health record stands for "orally related."

Question 35

Cutting into a body part without draining fluids and/or gases from the body part in order to separate or transect a body part is called ____.

A)reattachment
B)release
C)transfer
D)division

Question 36

Modifying the natural anatomic structure of a body part without affecting the function of the body part is called ____.

A)alteration
B)fusion
C)creation
D)repair

Question 37

Any procedure that affects payment or reimbursement must be reported.

Question 38

Completely closing an orifice or lumen of a tubular body part is called ____.

A)bypass
B)restriction
C)dilation
D)occlusion

Question 39

The Uniform Hospital Discharge Data Set (UHDDS) definitions are used by chronic care,long-term hospitals to report inpatient data elements in a standardized manner.

Question 40

An additional code should always be assigned for closure of the surgical incision.

Question 41

Putting back in or on all or a portion of a separated body part to its normal location or other suitable location is reattachment.

Question 42

A device is left in place after the completion of the procedure.

Question 43

The root operation "insertion" always involves a device.

Question 44

Altering the route of passage of the contents of a tubular body part is bypass.

Question 45

Sutures are considered a device.

Question 46

Ligatures,sutures,and clips are not considered to be devices.

Question 47

The type of instrumentation is a component in determining the approach.

Question 48

The AMA is responsible for the maintenance of ICD-10-PCS.

Question 49

The fifth character value represents the body part in the medical and surgical section.

Question 50

The entry,by puncture or minor incision,of instrumentation through the skin or mucous membrane and any other body layers necessary to reach the operative site is an open approach.

Question 51

All ICD-10-PCS codes have six characters.

Question 52

The Centers for Medicare and Medicaid (CMS) are responsible for the maintenance of ICD-10-PCS.

Question 53

Physical eradication of all or a portion of a body part by the direct use of energy,force,or a destructive agent is extraction.

Question 54

It is required that a coder use the Index to assign an ICD-10-PCS code.

Question 55

A character "Z" is available to indicate that no qualifier is necessary for a given procedure.

Question 56

The approach for removal of a skin lesion is external.

Question 57

The root operation "replacement" always involves a device.

Question 58

A character "X" is available to indicate that no qualifier is necessary for a given procedure.

Question 59

The approach for a laparoscopic cholecystectomy is percutaneous endoscopic.

Question 60

ICD-10-PCS is required only for inpatient billing by hospitals.

Question 61

The root operation to stop postprocedural bleeding is "control."

Question 62

When a patient is having a hip replacement,a code for the resection of a joint is assigned in addition to the joint replacement code.

Question 63

A bone marrow transplant is coded to the root operation transplant.

Question 64

Procedures performed on the skin are coded to the body part values in the body system skin and breast.

Question 65

The body site for perirenal is peritoneum.

Question 66

It is acceptable to use a general body part value,if available,when the specific body part cannot be determined.

Question 67

Exploration or inspection of a body part(s) that is integral to the performance of the procedure is not coded separately.

Question 68

Temporary post-operative wound drains are considered devices when assigning an ICD-10-PCS code.

Question 69

If the intended procedure is discontinued,code to the root operation that was intended.

Question 70

It is not acceptable to choose a valid code directly from the tables.

Question 71

If the identical procedure is performed on contralateral body parts and a bilateral body part value is available for that body part,a single code with the bilateral body part should be assigned.

Question 72

It is acceptable to choose a valid code directly from the tables.

Question 73

Body systems designated as "lower" contain body parts below the diaphragm.

Question 74

The resection of tonsils is coded to an open approach.

Question 75

Procedures that are performed using an open approach with percutaneous endoscopic assistance are coded to open approach.

Question 76

A closed reduction of a fracture is coded to the manipulation approach.

Question 77

The term "and" when used in a code description means "and/or."

Question 78

A device is coded only if the device remains after the procedure is completed.

Question 79

The root operation "extraction" always involves a device.

Question 80

Body systems designated as "upper" contain body parts above the heart.