Clinical Coding and Classification Systems
Exam Questions
Course Introduction
This course provides a comprehensive overview of clinical coding and classification systems used in healthcare to ensure accurate documentation, billing, and statistical analysis. Students will gain knowledge of major coding systems such as ICD, CPT, and HCPCS, learning how to apply coding guidelines to medical records across various specialties. The course emphasizes the importance of coding accuracy, compliance with regulations, and the role of classification systems in supporting healthcare delivery, research, and reimbursement. Through practical exercises and case studies, students will develop the skills necessary to interpret medical documentation and assign appropriate codes, preparing them for roles in health information management and medical coding.
Recommended Textbook
ICD 10 CM PCS Coding Theory and Practice 2018 Edition 1st Edition by Karla
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26 Chapters
1616 Verified Questions
1616 Flashcards
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R. Lovaasen
Chapter 1: The Rationale for and History of Coding
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47 Verified Questions
47 Flashcards
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Sample Questions
Q1) CPC-H stands for Certified Professional Coder-Health Care Based.
A)True
B)False Answer: False
Q2) Both AHIMA and AAPC have standards for ethical coding.
A)True
B)False Answer: True
Q3) Which coding credential requires coders to be familiar with Hierarchical Condition Categories (HCCs), which are the basis for reimbursement for Medical Advantage plans?
A)CIC
B)CRC
C)CPC
D)CCS-P Answer: B
Q4) CCS-P stands for Certified Coding Specialist-Pediatric Based.
A)True
B)False Answer: False
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Chapter 2: The Health Record As the Foundation of Coding
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42 Verified Questions
42 Flashcards
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Sample Questions
Q1) What year did the Uniform Hospital Discharge Data Set (UHDDS) mandate that hospitals must report a common core of data?
Answer: 1974
Q2) What are three of the five purposes of a health record?
Answer: The following are purposes of a health record: Describes the patient's health history
Serves as a method for clinicians to communicate regarding the treatment plan of care for the patient
Serves as a legal document of care and services provided Serves as a source of data
Serves as a resource for health care practitioner education
Q3) Abnormal findings (lab, x-ray, pathologic, and other diagnostic results) are always coded and reported when they are found.
A)True
B)False
Answer: False
Q4) Which report should be written or dictated immediately following a procedure?
Answer: Operative report
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4
Chapter 3: ICD-10-Cm Format and Conventions
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39 Verified Questions
39 Flashcards
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Sample Questions
Q1) The bolded subterm in the diagnostic statement purulent pneumonia is a(n) ____ modifier.
A)essential
B)nonessential
Answer: B
Q2) In ICD-10-CM the final character of a code assignment can never be a letter.
A)True
B)False
Answer: False
Q3) There are manifestation codes that DO NOT have "in diseases classified elsewhere" in the title. For such codes, a "use additional code" note will still be present at the etiology code and a "code first" note at the manifestation code, and the rules for sequencing still apply.
A)True
B)False
Answer: True
Q4) What does NEC stand for?
Answer: Not elsewhere classifiable
Q5) Why is it important for the coder to understand coding conventions?
Answer: Ensures accurate assignment and sequencing of codes
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Chapter 4: Basic Steps of Coding
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35 Verified Questions
35 Flashcards
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Sample Questions
Q1) When a patient displays a symptom that could represent a variety of diagnoses
A)Tabular List
B)See also
C)Subterms
D)Discharge summary
E)Coding Clinic
F)ER
G)Differential diagnosis
H)Chief complaint
I)The first basic step in coding the principal diagnosis
J)Nonessential modifiers
Q2) A coder must always remember that, after a term is located in the Alphabetic Index, the code must be verified in the Tabular List.
A)True
B)False
Q3) After a code has been selected from the Alphabetic Index to Diseases, what is the next step?
Q4) The admitting diagnosis is usually a sign or a symptom.
A)True
B)False
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Chapter 5: General Coding Guidelines for Diagnosis
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27 Flashcards
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Sample Questions
Q1) When the patient is admitted for a complication due to a surgical procedure, the complication is the principal diagnosis.
A)True
B)False
Q2) What is/are the diagnosis code(s) for acute and chronic cholecystitis?
Q3) A(n) __________ code is a single code used to classify two diagnoses, a diagnosis with an associated secondary process, or a diagnosis with an associated complication.
Q4) List one reason when it is NOT acceptable to code a symptom code from Chapter 18.
Q5) If a patient is admitted for a complication due to a surgical procedure, the reason for the surgical procedure is the principal diagnosis.
A)True
B)False
Q6) If the principal diagnosis was abdominal pain due to acute appendicitis, the abdominal pain would be coded as a secondary diagnosis.
A)True
B)False
Q7) What is/are the diagnosis code(s) for acute and chronic renal failure?
Page 7
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Chapter 6: Introduction to Icd-10-PCS
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127 Verified Questions
127 Flashcards
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Sample Questions
Q1) Endometrial ablation via natural opening, endoscopic
Q2) 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.
A)True
B)False
Q3) Open partial nephrectomy, left
Q4) A device is left in place after the completion of the procedure.
A)True
B)False
Q5) A character "Z" is available to indicate that no qualifier is necessary for a given procedure.
A)True
B)False
Q6) The Centers for Medicare and Medicaid Services (CMS) are responsible for the maintenance of ICD-10-PCS.
A)True
B)False
Q7) Which character identifies the body part in an ICD-10-PCS code?
Q8) Alphabetic Index entry for repair dura mater
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Chapter 7: General Coding Guidelines for Other Medical-
and Surgical-Related Procedures and Ancillary Procedures
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109 Verified Questions
109 Flashcards
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Sample Questions
Q1) Root type is the sixth character in the physical rehabilitation and diagnostic audiology section.
A)True
B)False
Q2) Packing wound, abdomen wall
Q3) The first character value for an imaging procedure is B.
A)True
B)False
Q4) Acupuncture can be coded in the other procedures section of ICD-10-PCS.
A)True
B)False
Q5) Removal of packing from right nare
Q6) Planar bone scan, entire musculoskeletal using Tc-99m
Q7) Nonautologous bone marrow transplant via central venous catheter, unrelated donor
Q8) Isotope is the sixth character in the radiation oncology section.
A)True
B)False
Q9) ECMO, circulatory, continuous Page 9
Q10) Mechanical respiratory ventilation less than 24 hours
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Page 10
Chapter 8: Coding Medical and Surgical Procedures
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66 Verified Questions
66 Flashcards
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Sample Questions
Q1) 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
Q2) Heart transplant, cadaver donor with extracorporeal circulation auxiliary during the open-heart surgery
Q3) Transurethral endoscopic laser ablation of prostate
Q4) Nonexcisional debridement of skin-right foot ulcer
Q5) 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
Q6) Frenulotomy for treatment of ankyloglossia
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Page 11
Chapter 9: Symptoms, Signs, and Abnormal
Clinical
and
Laboratory Findings Not Elsewhere Classified, and Z Codes
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Sample Questions
Q1) Patient is admitted for workup of normal-pressure hydrocephalus (NPH) because of ataxic gait. NPH is ruled out, and the patient is discharged home: __________
Q2) Gas pain: __________
Q3) Screening for sickle cell disorder: __________
Q4) Camp physical: __________
Q5) A Z code for long-term use of antibiotics should not be assigned when antibiotics are taken for a short period of time for an acute illness.
A)True
B)False
Q6) Vaccination
A)A primary circumstance for using Z codes
B)Symptom
C)Screening exam
D)Is a main term in the Alphabetic Index
E)Sign
Q7) Exposure to syphilis: __________
Q8) What is meant by screening exam or test?
Q9) Counseling on the initiation of contraceptive foam use: __________ Page 12
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Chapter 10: Certain Infectious and Parasitic Diseases
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64 Verified Questions
64 Flashcards
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Sample Questions
Q1) Assign the code for infectious diarrhea.
Q2) A patient was admitted with a diagnosis of urosepsis. Urine and blood cultures were performed on admittance. Blood cultures came back positive for Escherichia coli. Discharge summary documents sepsis due to Escherichia coli. Urinary tract infection.
A)N39.0, B96.20
B)A41.51, N39.0
C)A41.5, R65.20
D)N39.0, B96.20, R65.20
Q3) A patient was admitted to the hospital with fever, cough, and low blood pressure. Chest x-ray shows infiltrates, and sputum culture is positive for MRSA. The discharge summary indicates that the patient was admitted and was given IV antibiotics for MRSA pneumonia.
A)Z16.11, J15.212
B)J15.212, Z16.11
C)B95.62, Z16.11
D)J15.212
Q4) ____________________, or shingles, is a disease caused by the same virus that causes chickenpox.
Q5) TB stands for ____________________.
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Chapter 11: Neoplasms
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70 Flashcards
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Sample Questions
Q1) A patient is being treated for chemotherapy-induced anemia. Patient is receiving chemotherapy for right renal cell carcinoma.
A)C64.9, D63.0, T45.1X1A
B)D64.89, T45.1X1A, C64.2
C)C64.1, D64.81, T45.1X5A
D)D64.81, T45.1X5A, C64.1
Q2) What is the abbreviation for small-cell lung cancer?
Q3) Carcinomas in situ are malignant cells that remain within the original site with no spread to or invasion of neighboring tissues.
A)True
B)False
Q4) Neoplasms can affect ONLY certain specific body systems.
A)True
B)False
Q5) CDC stands for ____________________.
Q6) The administration of cancer-killing drugs is called ____________________.
Q7) Cancer of the white blood cells that begins in the blood-forming cells of the bone marrow is called ____________________.
Q8) Benign neoplasm of Cowper's gland: __________
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Chapter 12: Diseases of the Blood and Blood-Forming
Organs and Certain Disorders Involving the Immune
Mechanism
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72 Verified Questions
72 Flashcards
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Sample Questions
Q1) Postoperative anemia: __________
Q2) Anemia due to chronic kidney disease can be used as the principal diagnosis code in ICD-10-CM if the reason for the encounter is to treat the anemia.
A)True
B)False
Q3) A patient has anemia due to metastatic bone cancer. Patient has a history of primary left breast cancer that was treated with a mastectomy 4 years ago. No current treatment for the breast cancer.
A)C79.51, D63.8, Z85.3, Z90.12
B)D63.8, C79.52, Z85.3, Z90.11
C)C79.51, D63.0, Z85.3, Z90.12
D)D63.0, C79.51, Z85.3, Z90.11
Q4) Familial erythrocytosis: __________
Q5) All of the following are symptoms of anemia EXCEPT ____.
A)hot flashes
B)numbness and tingling sensations
C)headaches
D)brittle nails
Q6) Anemia due to acute blood loss: __________ Page 16
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Page 17
Chapter 13: Endocrine, Nutritional, and Metabolic Diseases
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68 Verified Questions
68 Flashcards
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Sample Questions
Q1) An adult patient was seen in the clinic for dietary counseling for dysmetabolic syndrome X. The patient is obese with a BMI of 35 and has hypertriglyceridemia and hypertension.
A)Z71.3, E88.81, E66.9, Z68.35, E78.1, I10
B)Z71.9, E88.81, E66.3, Z68.35, E78.1, I10
C)E88.81, E66.9, Z68.35, E78.1, I10, Z71.3
D)E66.9, E88.81, Z68.35, E78.1, I10, Z71.3
Q2) The ____ regulates metabolism of glucose in body cells and maintains proper blood glucose.
A)thymus
B)pancreas
C)pineal gland
D)adrenal medulla
Q3) When blood sugar becomes abnormally low, it is called ____.
A)hyperglycemia
B)hypoglycemia
C)hyperpituitarism
D)hypopituitarism
Q4) Diabetes mellitus with hypoglycemic coma: __________
Q5) What is exophthalmos?
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Chapter 14: Mental, Behavioral, and Neurodevelopmental Disorders
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72 Verified Questions
72 Flashcards
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Sample Questions
Q1) Irrational anxieties or fears that can interfere with one's everyday life routine
A)Sexual problems
B)PTSD-posttraumatic stress disorder
C)Phobias
D)Panic disorder
E)Generalized anxiety disorder
F)Mood disorders
G)Schizophrenia
Q2) Name one occurrence during birth that can cause intellectual disability.
Q3) Drug withdrawal treatment depends on the drug from which a person is having withdrawal.
A)True
B)False
Q4) What drug could be given to treat depression?
A)Adderall
B)Zoloft
C)Valium
D)Dilantin
Q5) Cirrhosis of liver due to alcohol dependence in remission: __________
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Chapter 15: Diseases of the Nervous System, Diseases of
the Eye and Adnexa, and Diseases of the Ear and Mastoid Process
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Sample Questions
Q1) What are the two main divisions of the nervous system?
Q2) The two parts of the peripheral nervous system are the ____________________ nervous system and the ___________________ nervous system.
Q3) Disorder of the optic nerve resulting in vision loss
A)Glaucoma
B)Hydrocephalus
C)Meningitis
D)Epilepsy
E)Parkinson disease
F)Cataract
G)Cholesteatoma
H)Mastoiditis
I)Myasthenia gravis
J)Alzheimer disease
Q4) Hydrocephalus can be acquired or congenital.
A)True
B)False
Page 20
Q5) A(n) ____________________ is a device that is used to treat intractable epilepsy.
Mastoid cholesteatoma of the right ear: __________
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Chapter 16: Diseases of the Circulatory System
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Sample Questions
Q1) Benign renovascular hypertension: __________
Q2) A patient is admitted with dyspnea and fluid overload. Chest X-ray reveals bilateral pleural effusion, right greater than left, and pulmonary congestion with possible congestive heart failure. BNP is elevated, confirming congestive heart failure. Echo shows a mild pulmonary hypertension and aortic valve stenosis. The patient is receiving medication for atrial fibrillation and has alcoholic cardiomyopathy and alcohol dependence.Discharge Diagnoses: Congestive heart failure
Pulmonary hypertension
Aortic valve stenosis
Atrial fibrillation
Q3) Patient has atherosclerosis of the left femoral artery with intermittent claudication and rest pain. An open fem-pop bypass (left) using synthetic substitute is performed on this patient with a chronic total occlusion.
A)I70.92, I70.222, 041L0JJ
B)I70.222, I70.91, 041L0JM
C)I70.222, I70.92, 041L0JL
D)I70.221, 41L0KL
Q4) Stenosis of bilateral carotid arteries: __________
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Chapter 17: Diseases of the Respiratory System
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Sample Questions
Q1) Patient is admitted with acute on chronic respiratory failure due to emphysema. Patient is dependent on oxygen and has had numerous admissions for pneumonia. Patient is treated with continuous BIPAP for 48 hours and is a DNR/DNI. No infection is identified, and deterioration in respiratory status is thought to be a progression of his emphysema. Patient was made comfort care and was discharged to at-home hospice care the following day.Final Diagnoses: End-stage emphysema
Acute on chronic respiratory failure with hypoxia
Procedure: BIPAP
A)J96.00, J43.0, Z99.81, Z87.01, Z51.5, 5A09557
B)J96.01, J43.9, Z99.81, Z87.01, Z66, 5A09357
C)J96.21, J43.9, Z99.81, Z87.01, Z66, Z51.5, 5A09457
D)J96.22, J43.9, Z99.81, Z87.01, 5A09357
Q2) Broncholithiasis: __________
Q3) Sometimes it is necessary to make an emergency artificial opening in a patient's neck into the trachea when the normal airway is blocked. This is called a(n)
Q4) Retropharyngeal abscess: __________
Q5) Idiopathic pulmonary fibrosis with transbronchial right lung biopsy via bronchoscope: __________
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Chapter 18: Diseases of the Digestive System
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Sample Questions
Q1) Mallory-Weiss tear is a name for a(n) ____________________ laceration of the esophagogastric junction, usually after severe vomiting.
Q2) Patient comes to the ER with severe abdominal pain and a long history of alcoholism. Physician documents that patient is currently drinking a fifth of liquor a day. Patient is admitted to the hospital with a diagnosis of acute pancreatitis secondary to alcohol use.
A)K85.80, F10.10
B)K85.20, F10.20
C)K85.90, F10.10
D)K85.00, F10.20
Q3) What is the term for degeneration of the liver tissue that causes blockage of the blood through the liver and inhibits its function?
Q4) Assign the code for hematemesis: __________
Q5) Which of the following esophageal conditions is most commonly treated with Prilosec?
A)Esophageal hemorrhage
B)Mallory-Weiss tear
C)Diverticulitis
D)Esophageal reflux
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Chapter 19: Diseases of the Skin and Subcutaneous System
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Sample Questions
Q1) What are two accessory organs of the integumentary system?
Q2) Clusters of boils are known as a ____.
A)furuncle
B)cellulitis
C)carbuncle
D)none of the above is correct
Q3) A skin condition also known as urticaria wherein the skin reacts with welts characterized by itching
A)Decubitus ulcer
B)Skin ulcers
C)Cellulitis
D)Stasis ulcer
E)Stasis dermatitis
F)Intertriginous dermatitis
G)Gangrene
H)Hives
I)Dermatitis
Q4) The sebaceous glands secrete an oily substance called ____________________.
Q5) Rhinophyma: __________
Q6) Nail horn, left thumb: __________
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Chapter 20: Diseases of the Musculoskeletal System and Connective Tissue
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Sample Questions
Q1) ____ is when one vertebra slips on another.
A)Facet joint
B)Spondylosis
C)Spinal stenosis
D)Spondylolisthesis
Q2) Right plantar fasciitis: __________
Q3) An 83-year-old woman with severe back pain is admitted. CT shows osteoporosis and possible compression fracture of the lumbar spine. The patient is seen by interventional radiology, and a percutaneous vertebroplasty is performed.Discharge
Diagnosis: Pathologic fracture of lumbar vertebra due to senile osteoporosis
A)M81.0, M80.08xA, 0QU03JZ
B)M80.08xG, 0QS03ZZ
C)M80.08xA, 0QU03JZ
D)M80.08xA, 0QS03ZZ
Q4) ICD-10-CM uses the sixth character when coding to identify pathologic fractures.
A)True
B)False
Q5) Internal derangement of left knee: __________
Q6) Tennis elbow (right): __________
Q7) Staphylococcal pyogenic arthritis of left knee: __________ Page 26
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Chapter 21: Diseases of the Genitourinary System
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Sample Questions
Q1) If causative bacteria are documented by the physician, this code should NEVER be coded in addition to the urinary tract infection.
A)True
B)False
Q2) A patient is admitted with acute pyelonephritis. Blood cultures are negative, but urine cultures are positive for Escherichia coli. The patient is treated with IV fluids and antibiotics.Discharge Diagnosis: Acute pyelonephritis due to E. coli
A)N11.1, B96.89
B)N11.9, B96.29
C)N10, B96.89
D)N10, B96.20
Q3) Hydronephrosis is the abnormal ____________________ of the renal pelvis caused by pressure from urine that cannot flow past an obstruction in the urinary tract.
Q4) Hypotonic bladder: __________
Q5) Leukoplakia of vulva: __________
Q6) Male patient with intrinsic sphincter deficiency with urinary stress incontinence with insertion of artificial bladder neck sphincter via open approach: __________
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Chapter 22: Pregnancy, Childbirth, and the Puerperium
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Sample Questions
Q1) The patient is admitted to the hospital in preterm labor. She is 27 weeks' pregnant. Terbutaline is administered, and the patient remains on bed rest. In the third week of bed rest, her water breaks, and she is taken to the delivery room. She vaginally delivers a baby girl.
A)O60.12x1, Z38.00, Z3A.27, 10E0XZZ.
B)O60.13x0, Z37.0, Z3A.27, 10E0XZZ
C)O60.12x1, Z38.00, Z3A.27, 10E0XZZ
D)O60.130, Z37.0, Z3A.27, 10E0XZZ
Q2) First pregnancy
3. 35 years of age or older at date of delivery
A)Young obstetric patient
B)Antepartum
C)Primigravida
D)Puerperium
E)Gravid
F)Elderly OB patient
Q3) What does it mean when a pregnant woman is called primigravida?
Q4) A term that means before delivery is _____________________.
Q5) Missed abortion: __________
Q6) Suppressed lactation postpartum: __________
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Chapter 23: Certain Conditions Originating in the Perinatal
Period and Congenital Malformations, Deformations, and
Chromosomal Abnormalities
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Q1) Polydactyly fingers: __________
Q2) A disorder that involves incomplete development of the brain, spinal cord, and/or their protective coverings
A)Klinefelter syndrome
B)Spina bifida
C)Meckel diverticulum
D)Marfan syndrome
E)Tetralogy of Fallot
F)Down syndrome
Q3) Prematurity is based on recorded birth weight and gestational age and documentation of prematurity.
A)True
B)False
Q4) Cesarean delivery at term of interlocking twins, twin A: __________
Q5) Which of the following makes a condition clinically significant?
A)The condition requires a clinical evaluation.
Page 30
B)The condition requires therapeutic treatment.
C)The condition requires an extended hospital stay.
D)All of the above are correct.
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Chapter 24: Injuries and Certain Other Consequences of
External Cases and External Causes of Morbidity
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Q1) Any mechanical injury that results in hemorrhage beneath unbroken skin
A)Crush injury
B)Fissured fracture
C)Comminuted fracture
D)Greenstick fracture
E)External skeletal fixation
F)Contusion
Q2) When the surgeon makes an incision at the fracture site to reduce or manipulate the fracture into anatomic position, this is called ____ of a fracture.
A)open reduction
B)closed reduction
C)suture
D)Dermabond
Q3) Which of the following is NOT a common site for a laceration?
A)Above the eyebrows
B)Scalp
C)Stomach
D)Knees
E)Face
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Q4) A(n) ____________________ fracture causes injury to the surrounding tissues.
Chapter 25: Burns, Adverse Effects, and Poisonings
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Q1) A patient combined prescription Percodan with beer and became stuporous and drowsy.
A)T40.2x1A, T51.0x1A, R40.1, R40.0
B)T40.2x1D, T51.0x1D, R40.1, R40.0
C)T40.2x1S, T51.0x1S, R40.1, R40.0
D)T40.2x1A, T51.0x1A
Q2) In a toxic poisoning the toxic poisoning code (T36-T50) should be sequenced first, followed by the external cause code(s).
A)True
B)False
Q3) Erythema or redness of the skin
A)First-degree
B)Second-degree
C)Third-degree
D)Fourth-degree
Q4) Spontaneous hematoma in right thigh muscle due to anticoagulant; patient is taking Coumadin as prescribed for mechanical mitral valve replacement: __________
Q5) Patient had an adverse reaction to Cipro, which was taken as prescribed:
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Chapter 26: Complications of Surgical and Medical Care
Available Study Resources on Quizplus for this Chatper
48 Verified Questions
48 Flashcards
Source URL: https://quizplus.com/quiz/42599
Sample Questions
Q1) The term dehiscence means ____.
A)breathing in a foreign object
B)opening a surgical wound
C)caused by medical treatment
D)small amount of urine
Q2) A patient had a partial pancreatectomy for chronic pancreatitis and has now developed postpancreatectomy diabetes mellitus along with diabetic nephrosis.
A)E09.69, E89.1, E13.21
B)E08.21, E89.1, Z90.410, Y83.6
C)E89.1, E13.21, Z90.411, Y83.6
D)E89.1, E08.21, E13.21
Q3) Patient with an intestine transplant with diverticulitis of the intestinal graft:
Q4) Mechanical complication of gastrostomy: __________
Q5) Complications affect only certain body systems.
A)True
B)False
Q6) Can code Z94.0 and a T86.1-code be used together?
Q7) Leaking silicone breast implant, initial visit: __________
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