Chapter 01
Introduction to Diagnostic Coding
2017 Compliant

Multiple Choice Questions
 
1.  A ________ code reports why the patient was seen by the physician.  
A.  condition 
B.  diagnosis 
C.  procedure 
D.  status 
 The diagnosis, or diagnostic statement, will explain why the patient was seen and treated. 

ABHES: 8.c.3. Perform diagnostic and procedural coding
Accessibility: Keyboard Navigation
Blooms: Remember
CAAHEP: IX.C.2. Describe how to use the most current diagnostic coding classification system
CAHIIM: I.A.1. Apply diagnosis/procedure codes according to current guidelines
Difficulty: 1 Easy
Est Time: 0-1 min
Learning Outcome: 01.01
Topic: The Purpose of Coding

 
2.  Diagnosis codes can report a disease, a sign, or a(n) ________.  
A.  purpose 
B.  treatment 
C.  symptom 
D.  objective 
 A symptom is an indication of an abnormal state as described by the patient. The physician's notes may include a diagnosis that identifies a specific condition or illness, the signs or symptoms of an unnamed problem, or another reason for the encounter. 

ABHES: 8.c.3. Perform diagnostic and procedural coding
Accessibility: Keyboard Navigation
Blooms: Remember
CAAHEP: IX.C.2. Describe how to use the most current diagnostic coding classification system
CAHIIM: I.A.1. Apply diagnosis/procedure codes according to current guidelines
Difficulty: 1 Easy
Est Time: 0-1 min
Learning Outcome: 01.01
Topic: The Purpose of Coding
 
3.  A fever is an example of a(n) _________.  
A.  sign 
B.  objective 
C.  sensation 
D.  code 
 A sign is an indication of an abnormal state that can be measured. A patient's temperature can be measured with a thermometer. 

ABHES: 8.c.3. Perform diagnostic and procedural coding
Accessibility: Keyboard Navigation
Blooms: Apply
CAAHEP: IX.C.2. Describe how to use the most current diagnostic coding classification system
CAHIIM: I.A.1. Apply diagnosis/procedure codes according to current guidelines
Difficulty: 1 Easy
Est Time: 0-1 min
Learning Outcome: 01.01
Topic: The Purpose of Coding

 
4.  A ____________ is a subjective sensation as expressed by the patient.  
A.  symptom 
B.  treatment 
C.  diagnosis 
D.  condition 
 A symptom is an indication of an abnormal state as described by the patient. There is no way to measure a symptom such as a headache or dizziness. 

ABHES: 8.c.3. Perform diagnostic and procedural coding
Accessibility: Keyboard Navigation
Blooms: Remember
CAAHEP: IX.C.2. Describe how to use the most current diagnostic coding classification system
CAHIIM: I.A.1. Apply diagnosis/procedure codes according to current guidelines
Difficulty: 1 Easy
Est Time: 0-1 min
Learning Outcome: 01.01
Topic: The Purpose of Coding
 
5.  Hypertension is an example of a ____________.  
A.  symptom 
B.  diagnosis 
C.  procedure 
D.  complaint 
 Hypertension is a diagnosis. High blood pressure is a sign because it can be measured with a sphygmomanometer (commonly referred to as a blood pressure cuff) and can be diagnosed. 

ABHES: 8.c.3. Perform diagnostic and procedural coding
Accessibility: Keyboard Navigation
Blooms: Apply
CAAHEP: IX.C.2. Describe how to use the most current diagnostic coding classification system
CAHIIM: I.A.1. Apply diagnosis/procedure codes according to current guidelines
Difficulty: 1 Easy
Est Time: 0-1 min
Learning Outcome: 01.01
Topic: The Purpose of Coding

 
6.  Asthma is an example of a(n) ____________.  
A.  diagnosis 
B.  procedure 
C.  indication 
D.  opinion 
 Code each diagnosis and/or appropriate signs or symptoms describing why the health care provider treated this patient during this encounter, as documented in his or her notes. Use the best, most accurate code available based on that documentation. 

ABHES: 8.c.3. Perform diagnostic and procedural coding
Accessibility: Keyboard Navigation
Blooms: Understand
CAAHEP: IX.C.2. Describe how to use the most current diagnostic coding classification system
CAHIIM: I.A.1. Apply diagnosis/procedure codes according to current guidelines
Difficulty: 1 Easy
Est Time: 0-1 min
Learning Outcome: 01.02
Topic: Seven Steps to Accurate Coding
 
7.  ICD-10-CM contains codes for reporting ______________.  
A.  diagnoses 
B.  payers 
C.  systems 
D.  treatments 
 ICD-10-CM is a directory of every diagnosis, sign, symptom, or other valid reason that could possibly be identified by a health care provider with regard to a patient encounter. 

ABHES: 8.c.3. Perform diagnostic and procedural coding
Accessibility: Keyboard Navigation
Blooms: Remember
CAAHEP: IX.C.2. Describe how to use the most current diagnostic coding classification system
CAHIIM: I.A.1. Apply diagnosis/procedure codes according to current guidelines
Difficulty: 1 Easy
Est Time: 0-1 min
Learning Outcome: 01.01
Topic: The Purpose of Coding

 
8.  The diagnosis code(s) ___________ the procedure provided to the patient during the encounter.  
A.  cause 
B.  justify 
C.  explain 
D.  document 
 The diagnosis codes that you assign justify the procedure, service, or treatment the health care professional provided to the patient during the encounter. 

ABHES: 8.c.3. Perform diagnostic and procedural coding
Accessibility: Keyboard Navigation
Blooms: Remember
CAAHEP: IX.C.2. Describe how to use the most current diagnostic coding classification system
CAHIIM: I.A.2. Evaluate the accuracy of diagnostic and procedural coding
Difficulty: 1 Easy
Est Time: 0-1 min
Learning Outcome: 01.01
Topic: The Purpose of Coding
 
9.  Outpatient coders cannot assign a diagnosis code for a diagnosis documented as:  
A.  likely. 
B.  possible. 
C.  questionable. 
D.  All of these 
 An outpatient coder must follow outpatient coding guidelines, which state that a diagnosis documented as probable, suspected, likely, questionable, or possible is not coded. 

ABHES: 8.c.3. Perform diagnostic and procedural coding
Accessibility: Keyboard Navigation
Blooms: Understand
CAAHEP: IX.C.2. Describe how to use the most current diagnostic coding classification system
CAHIIM: I.A.2. Evaluate the accuracy of diagnostic and procedural coding
Difficulty: 1 Easy
Est Time: 0-1 min
Learning Outcome: 01.03
Topic: Official ICD-10-CM Guidelines for Coding and Reporting

 
10.  The official guidelines for ICD-10-CM are divided into ___ sections.  
A.  2 
B.  3 
C.  4 
D.  5 
 The guidelines are divided into four sections and an appendix: Section I—Conventions, General Coding Guidelines, and Chapter-Specific Guidelines; Section II—Selection of Principal Diagnosis; Section III—Reporting Additional Diagnoses; Section IV—Diagnostic Coding and Reporting Guidelines for Outpatient Services; Appendix I—Present on Admission Reporting Guidelines. 

ABHES: 8.c.3. Perform diagnostic and procedural coding
Accessibility: Keyboard Navigation
Blooms: Remember
CAAHEP: IX.C.2. Describe how to use the most current diagnostic coding classification system
CAHIIM: I.A.1. Apply diagnosis/procedure codes according to current guidelines
Difficulty: 1 Easy
Est Time: 0-1 min
Learning Outcome: 01.03
Topic: Official ICD-10-CM Guidelines for Coding and Reporting
 
11.  The rules for ethical coding include the requirement for __________________.  
A.  obligation 
B.  business 
C.  supporting documentation 
D.  claims 
 It is very important that the codes indicated on the health claim form represent the services actually performed and the reasons why they are provided as supported by the documentation in the patient's health record. Don't use a code on a claim form without ensuring the supporting documentation is there in the file. 

ABHES: 8.c.3. Perform diagnostic and procedural coding
Accessibility: Keyboard Navigation
Blooms: Remember
CAAHEP: IX.C.2. Describe how to use the most current diagnostic coding classification system
CAHIIM: I.B.3. Identify a complete health record according to, organizational policies, external regulations, and standards
Difficulty: 2 Medium
Est Time: 0-1 min
Learning Outcome: 01.04
Topic: Rules for Ethical and Legal Coding

 
12.  Coding for _________ means that the code was selected based on what the insurance company will pay rather than what the documentation reflects.  
A.  coverage 
B.  payment 
C.  services 
D.  documentation 
 Coding for coverage is choosing a code on the basis of what the insurance company will cover (pay for) rather than accurately reflecting the truth. 

ABHES: 8.c.3. Perform diagnostic and procedural coding
Accessibility: Keyboard Navigation
Blooms: Remember
CAAHEP: IX.C.2. Describe how to use the most current diagnostic coding classification system
CAHIIM: I.A.1. Apply diagnosis/procedure codes according to current guidelines
Difficulty: 1 Easy
Est Time: 0-1 min
Learning Outcome: 01.04
Topic: Rules for Ethical and Legal Coding
 
13.  _____________ is illegal because it reports a higher level of service or more severe condition than is true of the encounter with the patient.  
A.  Upcoding 
B.  Unbundling 
C.  Double billing 
D.  HIPAA 
 Upcoding is using a code on a claim form that indicates a higher level of service or a more severe aspect of disease or injury than is actual and true. 

ABHES: 8.c.3. Perform diagnostic and procedural coding
Accessibility: Keyboard Navigation
Blooms: Understand
CAAHEP: IX.C.4a. Discuss the effects of upcoding
CAHIIM: I.A.1. Apply diagnosis/procedure codes according to current guidelines
Difficulty: 1 Easy
Est Time: 0-1 min
Learning Outcome: 01.04
Topic: Rules for Ethical and Legal Coding

 
14.  You must code all ____________ or complications that are relevant to the current encounter.  
A.  admission diagnoses 
B.  conditions 
C.  factors 
D.  abuses 
 You must code all conditions or complications that are relevant to the current encounter. Failure to do so can be considered unethical. 

ABHES: 8.c.3. Perform diagnostic and procedural coding
Accessibility: Keyboard Navigation
Blooms: Understand
CAAHEP: VIII.P.4. Complete an insurance claim form
CAHIIM: I.A.1. Apply diagnosis/procedure codes according to current guidelines
Difficulty: 1 Easy
Est Time: 0-1 min
Learning Outcome: 01.04
Topic: Rules for Ethical and Legal Coding
 
15.  _____________ is the practice of sending a claim for the second time to the same insurance company for the same procedure to the same patient for the same service date.  
A.  Unbundling 
B.  Double billing 
C.  Coding 
D.  Recording 
 Double billing is sending a claim for the second time to the same insurance company for the same procedure or service, provided to the same patient on the same date of service. 

ABHES: 8.c.3. Perform diagnostic and procedural coding
Accessibility: Keyboard Navigation
Blooms: Remember
CAAHEP: VIII.P.4. Complete an insurance claim form
CAHIIM: I.A.1. Apply diagnosis/procedure codes according to current guidelines
Difficulty: 1 Easy
Est Time: 0-1 min
Learning Outcome: 01.04
Topic: Rules for Ethical and Legal Coding

 
16.  Statistics show that for every $1 spent to pay for health care fraud and abuse investigations and prosecutions, the government actually brings in ___ in returned money.  
A.  $1 
B.  $2 
C.  $4 
D.  $6 
 For every dollar that is spent to pay for health care fraud investigations and prosecutions by the government, $4 is returned. 

ABHES: 8.c.3. Perform diagnostic and procedural coding
Accessibility: Keyboard Navigation
Blooms: Remember
CAAHEP: VIII.P.4. Complete an insurance claim form
CAHIIM: I.A.1. Apply diagnosis/procedure codes according to current guidelines
Difficulty: 2 Medium
Est Time: 0-1 min
Learning Outcome: 01.04
Topic: Rules for Ethical and Legal Coding
 
17.  A ___________ dictionary can help a coder find an alternate term that might be easier to find in the ICD-10-CM manual.  
A.  medical 
B.  Latin 
C.  spelling 
D.  coding 
 A medical dictionary can help a coder find an alternate term that might be easier to find in the ICD-10-CM manual. 

ABHES: 8.c.3. Perform diagnostic and procedural coding
Accessibility: Keyboard Navigation
Blooms: Remember
CAAHEP: IX.C.2. Describe how to use the most current diagnostic coding classification system
CAHIIM: I.A.1. Apply diagnosis/procedure codes according to current guidelines
Difficulty: 1 Easy
Est Time: 0-1 min
Learning Outcome: 01.04
Topic: Rules for Ethical and Legal Coding

 
18.  ___________ created the Health Care Fraud and Abuse Control Program (HCFACP).  
A.  CMS 
B.  HIPAA 
C.  HHS 
D.  OIG 
 HIPAA created the Health Care Fraud and Abuse Control Program. 

ABHES: 8.c.3. Perform diagnostic and procedural coding
Accessibility: Keyboard Navigation
Blooms: Remember
CAAHEP: IX.C.2. Describe how to use the most current diagnostic coding classification system
CAHIIM: I.A.1. Apply diagnosis/procedure codes according to current guidelines
Difficulty: 1 Easy
Est Time: 0-1 min
Learning Outcome: 01.04
Topic: Rules for Ethical and Legal Coding
 
19.  The ________________ is a national organization for professional coding specialists.  
A.  Centers for Medicare and Medicaid Services 
B.  Office of the Inspector General 
C.  Department of Health and Human Services 
D.  American Health Information Management Association 
 The American Health Information Management Association (AHIMA) is the preeminent professional organization for health information workers, including coding specialists. 

ABHES: 8.c.3. Perform diagnostic and procedural coding
Accessibility: Keyboard Navigation
Blooms: Remember
CAAHEP: IX.C.2. Describe how to use the most current diagnostic coding classification system
CAHIIM: VI.H.1. Comply with ethical standards of practice
Difficulty: 1 Easy
Est Time: 0-1 min
Learning Outcome: 01.05
Topic: American Health Information Management Association Code of Ethics

 
20.  The ________________ can help a coder find the general or alternate name of a drug or an herbal remedy.  
A.  Physicians' Desk Reference 
B.  Merck Manual 
C.  Coding Clinic 
D.  medical dictionary 
 The Physicians' Desk Reference (PDR) will help you find alternative or generic names for drugs or other chemicals used in the patient's treatment that may have been prescribed by the physician, been taken incorrectly or accidentally, caused an allergic reaction, or had a toxic effect. 

ABHES: 8.c.3. Perform diagnostic and procedural coding
Accessibility: Keyboard Navigation
Blooms: Remember
CAAHEP: IX.C.2. Describe how to use the most current diagnostic coding classification system
CAHIIM: I.A.1. Apply diagnosis/procedure codes according to current guidelines
Difficulty: 1 Easy
Est Time: 0-1 min
Learning Outcome: 01.04
Topic: Rules for Ethical and Legal Coding
 
21.  Which of the following professional organizations has a code of ethics for coders to follow?  
A.  AAPC 
B.  AHIMA 
C.  Both AAPC and AHIMA 
D.  Neither AAPC nor AHIMA 
 AAPC and AHIMA both have a code of ethics for coders to follow. 

ABHES: 4.g. Display compliance with Code of Ethics of the profession
Accessibility: Keyboard Navigation
Blooms: Remember
CAAHEP: X.C.5. Discuss licensure and certification as they apply to healthcare providers
CAHIIM: VI.H.1. Comply with ethical standards of practice
Difficulty: 1 Easy
Est Time: 0-1 min
Learning Outcome: 01.05
Learning Outcome: 01.06
Topic: AAPC Code of Ethical Standards
Topic: American Health Information Management Association Code of Ethics

 
22.  What is the most important factor to consider when coding?  
A.  Accuracy 
B.  Productivity 
C.  Timeliness 
D.  All of these 
 The number one consideration when coding is accuracy. 

ABHES: 8.c.3. Perform diagnostic and procedural coding
Accessibility: Keyboard Navigation
Blooms: Remember
CAAHEP: IX.C.2. Describe how to use the most current diagnostic coding classification system
CAHIIM: I.A.1. Apply diagnosis/procedure codes according to current guidelines
Difficulty: 1 Easy
Est Time: 0-1 min
Learning Outcome: 01.02
Topic: Seven Steps to Accurate Coding
 
23.  Where are the Official Guidelines for Coding and Reporting published?  
A.  In Appendix A of the ICD-10-CM manual 
B.  In the front of the ICD-10-CM manual 
C.  In Section III of the ICD-10-CM manual 
D.  In Section IV of the ICD-10-CM manual 
 In the front of the ICD-10-CM manual, you will find the Official Guidelines for Coding and Reporting as issued by the Centers for Medicare and Medicaid Services (CMS) and the National Center of Health Statistics (NCHS), two departments within the U.S. government's Department of Health and Human Services (HHS). 

ABHES: 8.c.3. Perform diagnostic and procedural coding
Accessibility: Keyboard Navigation
Blooms: Remember
CAAHEP: IX.C.2. Describe how to use the most current diagnostic coding classification system
CAHIIM: I.A.1. Apply diagnosis/procedure codes according to current guidelines
Difficulty: 1 Easy
Est Time: 0-1 min
Learning Outcome: 01.03
Topic: Official ICD-10-CM Guidelines for Coding and Reporting

 
24.  Unbundling is an example of ________.  
A.  payment 
B.  fraud 
C.  coverage 
D.  penalties 
 Unbundling is coding the individual parts of a specific diagnosis or procedure rather than a combination or bundle that includes all of those components and is illegal. 

ABHES: 8.c.3. Perform diagnostic and procedural coding
Accessibility: Keyboard Navigation
Blooms: Understand
CAAHEP: IX.C.2. Describe how to use the most current diagnostic coding classification system
CAHIIM: V.C.1. Identify potential abuse or fraudulent trends through data analysis
Difficulty: 1 Easy
Est Time: 0-1 min
Learning Outcome: 01.04
Topic: Rules for Ethical and Legal Coding
 
25.  If a patient is diagnosed with chest pain due to an acute anterior wall myocardial infarction, what condition should be coded?  
A.  Chest pain 
B.  Myocardial infarction 
C.  Acute anterior wall myocardial infarction 
D.  Chest pain and acute anterior wall myocardial infarction 
 Code the diagnosis but no signs/symptoms associated with that diagnosis because they are integral to the condition. The chest pain is integral to the diagnosis of acute anterior wall myocardial infarction, and only the acute anterior myocardial infarction is coded. 

ABHES: 8.c.3. Perform diagnostic and procedural coding
Accessibility: Keyboard Navigation
Blooms: Understand
CAAHEP: IX.C.2. Describe how to use the most current diagnostic coding classification system
CAHIIM: I.A.1. Apply diagnosis/procedure codes according to current guidelines
Difficulty: 1 Easy
Est Time: 0-1 min
Learning Outcome: 01.04
Topic: Rules for Ethical and Legal Coding

 
26.  A diagnosis is a physician's determination of all of the following except a patient's:  
A.  illness. 
B.  injury. 
C.  condition. 
D.  procedure. 
 A physician's determination of a patient's condition, illness, or injury is known as the diagnosis. 

ABHES: 8.c.3. Perform diagnostic and procedural coding
Accessibility: Keyboard Navigation
Blooms: Remember
CAAHEP: IX.C.2. Describe how to use the most current diagnostic coding classification system
CAHIIM: VI.E.2. Explain return on investment for employee training/development
Difficulty: 1 Easy
Est Time: 0-1 min
Learning Outcome: 01.01
Topic: The Purpose of Coding
 
27.  Which of the following organ systems includes the brain and spinal cord?  
A.  Cardiovascular 
B.  Digestive 
C.  Nervous 
D.  Urinary 
 The nervous system includes the brain and spinal cord. 

ABHES: 8.c.3. Perform diagnostic and procedural coding
Accessibility: Keyboard Navigation
Blooms: Remember
CAAHEP: IX.C.2. Describe how to use the most current diagnostic coding classification system
CAHIIM: I.A.2. Evaluate the accuracy of diagnostic and procedural coding
Difficulty: 1 Easy
Est Time: 0-1 min
Learning Outcome: 01.04
Topic: Rules for Ethical and Legal Coding

 
28.  Which position describes a patient lying on her stomach face downward?  
A.  Prone 
B.  Supine 
C.  Sitting 
D.  Lithotomy 
 In the prone position, a patient is lying on his or her stomach facing downward. 

ABHES: 8.c.3. Perform diagnostic and procedural coding
Accessibility: Keyboard Navigation
Blooms: Remember
CAAHEP: IX.C.2. Describe how to use the most current diagnostic coding classification system
CAHIIM: I.A.2. Evaluate the accuracy of diagnostic and procedural coding
Difficulty: 1 Easy
Est Time: 0-1 min
Learning Outcome: 01.04
Topic: Rules for Ethical and Legal Coding
 
29.  A malignant neoplasm is a type of:  
A.  asthma. 
B.  bronchitis. 
C.  cancer. 
D.  dermatitis. 
 A malignant neoplasm is a type of cancer. 

ABHES: 2.b. Describe common diseases, symptoms and etiologies as they apply to each system
Accessibility: Keyboard Navigation
Blooms: Understand
CAAHEP: IX.P.2. Perform diagnostic coding
CAHIIM: I.A.1. Apply diagnosis/procedure codes according to current guidelines
Difficulty: 1 Easy
Est Time: 0-1 min
Learning Outcome: 01.02
Topic: Seven Steps to Accurate Coding

 
30.  Dizziness is an example of a:  
A.  symptom. 
B.  sign. 
C.  diagnosis. 
D.  procedure. 
 A symptom is a subjective sensation as expressed by the patient and cannot be measured. 

ABHES: 2.b. Describe common diseases, symptoms and etiologies as they apply to each system
Accessibility: Keyboard Navigation
Blooms: Remember
CAAHEP: IX.P.2. Perform diagnostic coding
CAHIIM: I.A.1. Apply diagnosis/procedure codes according to current guidelines
Difficulty: 1 Easy
Est Time: 0-1 min
Learning Outcome: 01.02
Topic: Seven Steps to Accurate Coding
 
31.  The abbreviation RUQ stands for _____________.  
A.  right lower quadrant 
B.  left upper quadrant 
C.  right upper quadrant 
D.  left lower quadrant 
The Four Quadrants: Using the belly button as the center, these areas are referred to as the left upper quadrant (LUQ), left lower quadrant (LLQ), right upper quadrant (RUQ), and right lower quadrant (RLQ). These descriptors may be used to describe the location of an organ or a symptom. For example, the appendix is located in the right lower quadrant. A patient’s complaint of pain in the RLQ may indicate possible appendicitis. 

ABHES: 8.c.3. Perform diagnostic and procedural coding
Accessibility: Keyboard Navigation
Blooms: Remember
CAAHEP: IX.C.2. Describe how to use the most current diagnostic coding classification system
CAHIIM: I.A.1. Apply diagnosis/procedure codes according to current guidelines
Difficulty: 1 Easy
Est Time: 0-1 min
Learning Outcome: 01.03
Topic: Official ICD-10-CM Guidelines for Coding and Reporting

 
32.  The seven steps of accurate coding include:  
A.  coding only documented conditions. 
B.  coding the problems told to you by the nurse. 
C.  coding only the chief complaint. 
D.  coding the patient's history. 
 Never assume or try to guess. Code only what you know from actual documentation. 

ABHES: 4.a. Follow documentation guidelines
Accessibility: Keyboard Navigation
Blooms: Understand
CAAHEP: IX.C.2. Describe how to use the most current diagnostic coding classification system
CAHIIM: I.A.1. Apply diagnosis/procedure codes according to current guidelines
Difficulty: 1 Easy
Est Time: 0-1 min
Learning Outcome: 01.02
Topic: Seven Steps to Accurate Coding
 
33.  If there is unclear information in the documentation, the coder should:  
A.  code the diagnosis as though it existed. 
B.  not code the diagnosis. 
C.  query the physician. 
D.  give the chart to the coding supervisor to code. 
 If there is unclear or missing information necessary to code the chart, the coder should query the physician for further clarification. 

ABHES: 4.a. Follow documentation guidelines
Accessibility: Keyboard Navigation
Blooms: Understand
CAAHEP: IX.C.2. Describe how to use the most current diagnostic coding classification system
CAHIIM: I.A.1. Apply diagnosis/procedure codes according to current guidelines
Difficulty: 2 Medium
Est Time: 0-1 min
Learning Outcome: 01.02
Topic: Seven Steps to Accurate Coding

 
34.  Justifying a procedure code with a diagnosis code is known as:  
A.  medical necessity. 
B.  the National Correct Coding Initiative. 
C.  unbundling. 
D.  upcoding. 
 Medical necessity is justifying the procedure, service, or treatment with a diagnosis to validate the reason for the procedure, service, or treatment. 

ABHES: 8.c.3. Perform diagnostic and procedural coding
Accessibility: Keyboard Navigation
Blooms: Remember
CAAHEP: IX.C.2. Describe how to use the most current diagnostic coding classification system
CAHIIM: I.A.1. Apply diagnosis/procedure codes according to current guidelines
Difficulty: 1 Easy
Est Time: 0-1 min
Learning Outcome: 01.01
Topic: The Purpose of Coding
 
35.  The physician's notes state, "Chest congestion, possible pneumonia." The coder in the physician's office should:  
A.  code for pneumonia. 
B.  code for chest congestion. 
C.  query the physician. 
D.  All of these 
 The guidelines in the Official ICD-10-CM Guidelines for Coding and Reporting will guide you toward the best, most accurate code and make coding decisions easier. Section IV, Diagnostic Coding and Reporting Guidelines for Outpatient Services, Subsection h states, “Do not code diagnoses documented as ‘probable’, ‘suspected’, ‘questionable’, ‘rule out’, or ‘working diagnosis.’ Rather, code the condition(s) to the highest degree of certainty for that encounter/visit.” 

ABHES: 4.a. Follow documentation guidelines
Accessibility: Keyboard Navigation
Blooms: Understand
CAAHEP: IX.C.2. Describe how to use the most current diagnostic coding classification system
CAHIIM: I.A.1. Apply diagnosis/procedure codes according to current guidelines
Difficulty: 2 Medium
Est Time: 0-1 min
Learning Outcome: 01.03
Topic: Seven Steps to Accurate Coding

 
36.  The abbreviation AP stands for _____________.  
A.  anteroposterior 
B.  posteroanterior 
C.  anterior oblique 
D.  posterior oblique 
 The abbreviation AP stands for anteroposterior. 

ABHES: 8.c.3. Perform diagnostic and procedural coding
Accessibility: Keyboard Navigation
Blooms: Remember
CAAHEP: IX.P.1. Perform procedural coding
CAHIIM: I.A.1. Apply diagnosis/procedure codes according to current guidelines
Difficulty: 1 Easy
Est Time: 0-1 min
Learning Outcome: 01.04
Topic: Rules for Ethical and Legal Coding
 
37.  The physician documented Jacob's diagnosis as a chest cold. The coder assigned a code for bronchitis. This is an example of:  
A.  coding for coverage. 
B.  double billing. 
C.  following correct coding guidelines. 
D.  upcoding. 
 Read the Official ICD-10-CM Guidelines for Coding and Reporting. 

ABHES: 8.c.3. Perform diagnostic and procedural coding
Accessibility: Keyboard Navigation
Blooms: Understand
CAAHEP: IX.P.1. Perform procedural coding
CAHIIM: I.A.1. Apply diagnosis/procedure codes according to current guidelines
Difficulty: 2 Medium
Est Time: 0-1 min
Learning Outcome: 01.04
Topic: Rules for Ethical and Legal Coding

 
38.  Which position describes a patient lying on his or her back with a headrest bringing the head and torso up at a 45-degree angle?  
A.  Sim's 
B.  Fowler's 
C.  Knee-elbow 
D.  Proctologic 
 In the Fowler's position, a patient lies on his or her back with a headrest bringing the head and torso up at a 45-degree angle. 

ABHES: 8.c.3. Perform diagnostic and procedural coding
Accessibility: Keyboard Navigation
Blooms: Remember
CAAHEP: X.C.4. Describe components of the Health Information Portability and Accountability Act (HIPAA)
CAHIIM: I.A.1. Apply diagnosis/procedure codes according to current guidelines
Difficulty: 2 Medium
Est Time: 0-1 min
Learning Outcome: 01.04
Topic: Rules for Ethical and Legal Coding
 
39.  It is important that coders use credible resources, including:  
A.  medical dictionaries. 
B.  the Merck Manual. 
C.  Wikipedia. 
D.  medical dictionaries and the Merck Manual. 
 Coders use a variety of credible resources when coding, including medical dictionaries and the Merck Manual. 

ABHES: 8.c.3. Perform diagnostic and procedural coding
Accessibility: Keyboard Navigation
Blooms: Remember
CAAHEP: IX.P.1. Perform procedural coding
CAHIIM: I.A.1. Apply diagnosis/procedure codes according to current guidelines
Difficulty: 1 Easy
Est Time: 0-1 min
Learning Outcome: 01.04
Topic: Rules for Ethical and Legal Coding

 
40.  A professional coder should not:  
A.  code any condition that has not been documented. 
B.  send queries to the physician who cared for the patient. 
C.  read the physician's notes thoroughly. 
D.  code to the highest specificity. 
 You must code all conditions or complications that are relevant to the current encounter. One absolute rule for coders is "if it's not documented, it didn't happen!" So you can't code it. 

ABHES: 8.c.3. Perform diagnostic and procedural coding
Accessibility: Keyboard Navigation
Blooms: Understand
CAAHEP: IX.P.2. Perform diagnostic coding
CAHIIM: I.A.1. Apply diagnosis/procedure codes according to current guidelines
Difficulty: 1 Easy
Est Time: 0-1 min
Learning Outcome: 01.02
Topic: Seven Steps to Accurate Coding
 
41.  Who published the coding resource Coding Clinic?  
A.  AMA 
B.  AHA 
C.  AHIMA 
D.  AAPC 
 The American Hospital Association publishes the Coding Clinic quarterly. 

ABHES: 4.a. Follow documentation guidelines
Accessibility: Keyboard Navigation
Blooms: Understand
CAAHEP: IX.C.2. Describe how to use the most current diagnostic coding classification system
CAHIIM: I.A.1. Apply diagnosis/procedure codes according to current guidelines
Difficulty: 2 Medium
Est Time: 0-1 min
Learning Outcome: 01.04
Topic: Rules for Ethical and Legal Coding

 
42.  ICD-10-CM is an acronym for:  
A.  International Classification of Diseases, Tenth Revision, Clinical Modification. 
B.  International Classification of Diseases, Tenth Revision, Current Modification. 
C.  International Classification of Diagnoses, Tenth Revision, Clinical Modification. 
D.  International Classification of Diagnoses, Tenth Revision, Current Modification. 
 The acronym ICD-10-CM stands for International Classification of Diseases, Tenth Revision, Clinical Modification. 

ABHES: 4.a. Follow documentation guidelines
Accessibility: Keyboard Navigation
Blooms: Understand
CAAHEP: IX.P.2. Perform diagnostic coding
CAHIIM: VI.D.3. Adhere to work plans, policies, procedures, and resource requisitions in relation to job functions
Difficulty: 1 Easy
Est Time: 0-1 min
Learning Outcome: 01.01
Topic: The Purpose of Coding
 
43.  A coder who acts illegally may be:  
A.  fined monetarily. 
B.  retrained. 
C.  sentenced to jail. 
D.  fined monetarily and sentenced to jail. 
 This is an important reminder that if individuals try to get you to participate in illegal or unethical behaviors, the question is not "Will you be caught?" but "When will you be caught?" It is not worth breaking the law and being charged with any of these penalties just to hang onto a job. 

ABHES: 8.c.3. Perform diagnostic and procedural coding
Accessibility: Keyboard Navigation
Blooms: Evaluate
CAAHEP: X.C.5. Discuss licensure and certification as they apply to healthcare providers
CAHIIM: I.A.1. Apply diagnosis/procedure codes according to current guidelines
Difficulty: 1 Easy
Est Time: 0-1 min
Learning Outcome: 01.04
Topic: Rules for Ethical and Legal Coding

 
44.  The directional term used to mean toward the bottom of the body is:  
A.  superior. 
B.  cephalad. 
C.  inferior. 
D.  caudal. 
Inferior means toward the bottom (the feet) of the body. 

ABHES: 8.c.3. Perform diagnostic and procedural coding
Accessibility: Keyboard Navigation
Blooms: Remember
CAAHEP: VIII.P.4. Complete an insurance claim form
CAHIIM: IV.A.2. Evaluate the revenue cycle management processes
Difficulty: 1 Easy
Est Time: 0-1 min
Learning Outcome: 01.04
Topic: Rules for Ethical and Legal Coding
 
45.  AHIMA stands for:  
A.  American Health Information Management Association. 
B.  American Healthcare Insurance Monitoring Association. 
C.  American Health and Insurance Marketing Association. 
D.  American Healthcare Information and Medical Association. 
 The American Health Information Management Association (AHIMA) is the preeminent professional organization for health information workers, including insurance coding specialists. 

ABHES: 4.g. Display compliance with Code of Ethics of the profession
Accessibility: Keyboard Navigation
Blooms: Remember
CAAHEP: XI.C.2. Differentiate between personal and professional ethics
CAHIIM: VI.H.1. Comply with ethical standards of practice
Difficulty: 1 Easy
Est Time: 0-1 min
Learning Outcome: 01.05
Topic: American Health Information Management Association Code of Ethics

 
46.  It is important for coders to understand:  
A.  medical terminology. 
B.  anatomy and physiology. 
C.  the Physicians' Desk Reference. 
D.  medical terminology and anatomy and physiology. 
 Professional coding specialists need to have a complete understanding of medical terminology in addition to the specifics of anatomy, etiology, and pathophysiology. 

ABHES: 3.a. Define and use entire basic structure of medical words and be able to accurately identify in the correct context, i.e. root, prefix, suffix, combinations, spelling, and definitions
Accessibility: Keyboard Navigation
Blooms: Understand
CAAHEP: I.C.8. Identify common pathology related to each body system including
CAHIIM: I.A.1. Apply diagnosis/procedure codes according to current guidelines
Difficulty: 1 Easy
Est Time: 0-1 min
Learning Outcome: 01.02
Topic: Seven Steps to Accurate Coding
 
47.  A patient complains of dizziness. The physician states that she has hypertension. You will:  
A.  code for dizziness. 
B.  code for hypertension. 
C.  code for dizziness and hypertension. 
D.  query the physician. 
 One of the reasons you, as a professional coding specialist, must learn about pathology and physiology is to distinguish between signs and symptoms that are included in a confirmed diagnosis and those that are not. Signs and symptoms that are integral to a confirmed diagnosis are not separately reported, whereas those that are included are coded separately.  

ABHES: 4.a. Follow documentation guidelines
Accessibility: Keyboard Navigation
Blooms: Apply
CAAHEP: IX.C.2. Describe how to use the most current diagnostic coding classification system
CAHIIM: I.A.1. Apply diagnosis/procedure codes according to current guidelines
Difficulty: 2 Medium
Est Time: 0-1 min
Learning Outcome: 01.02
Topic: Seven Steps to Accurate Coding

 
48.  Jane complains of nausea. Dr. Mason orders her to go to the lab for a blood test to rule out pregnancy. You code:  
A.  nausea. 
B.  unspecified. 
C.  pregnancy. 
D.  nausea and pregnancy. 
 The guidelines in the Official ICD-10-CM Guidelines for Coding and Reporting will guide you toward the best, most accurate code and make coding decisions easier. Section IV, Diagnostic Coding and Reporting Guidelines for Outpatient Services, Subsection H states, “Do not code diagnoses documented as ‘probable’, ‘suspected’, ‘questionable’, ‘rule out’, or ‘working diagnosis.’ Rather, code the condition(s) to the highest degree of certainty for that encounter/visit.” 

ABHES: 4.a. Follow documentation guidelines
Accessibility: Keyboard Navigation
Blooms: Apply
CAAHEP: IX.C.2. Describe how to use the most current diagnostic coding classification system
CAHIIM: I.A.1. Apply diagnosis/procedure codes according to current guidelines
Difficulty: 2 Medium
Est Time: 0-1 min
Learning Outcome: 01.03
Topic: Official ICD-10-CM Guidelines for Coding and Reporting
 
49.  What does AAPC stand for?  
A.  American Academy of Professional Coders 
B.  American Association of Professional Coders 
C.  American Academy of Physician Coders 
D.  American Association of Physician Coders 
 The AAPC is the American Academy of Professional Coders. 

ABHES: 8.c.2. Differentiate managed care; i.e. HMO, PPO, IPA including referrals and pre-certification
Accessibility: Keyboard Navigation
Blooms: Remember
CAAHEP: VIII.P.4. Complete an insurance claim form
CAHIIM: I.A.2. Evaluate the accuracy of diagnostic and procedural coding
Difficulty: 1 Easy
Est Time: 0-1 min
Learning Outcome: 01.06
Topic: AAPC Code of Ethical Standards

 
50.  Which of the following abbreviations is considered dangerous to use?  
A.  U 
B.  IU 
C.  Q.D. 
D.  All of these 
 All of these abbreviations are on the "Do Not Use" list created by the Joint Commission. 

ABHES: 1.d. List the general responsibilities & skills of the medical assistant
Accessibility: Keyboard Navigation
Blooms: Remember
CAAHEP: IX.P.2. Perform diagnostic coding
CAHIIM: VI.D.3. Adhere to work plans, policies, procedures, and resource requisitions in relation to job functions
Difficulty: 1 Easy
Est Time: 0-1 min
Learning Outcome: 01.04
Topic: Rules for Ethical and Legal Coding