Diagnostic and Procedural Coding Final Exam
Course Introduction
This course provides students with a comprehensive understanding of diagnostic and procedural coding systems used in healthcare settings, including ICD, CPT, and HCPCS. Emphasis is placed on the accurate translation of medical diagnoses and procedures into standardized codes for billing, insurance claims, and data collection. Through practical exercises and case studies, students develop the skills required to interpret medical documentation, apply coding guidelines, and ensure compliance with industry regulations. The course also addresses the ethical and legal aspects of coding, preparing students for roles in health information management and medical billing.
Recommended Textbook
ICD 10 CM PCS Coding Theory and Practice 2017 Edition 1st Edition by Karla R. Lovaasen
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26 Chapters
1611 Verified Questions
1611 Flashcards
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2
Chapter 1: The Rationale for and History of Coding
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Sample Questions
Q1) In a closed system like the ICD-10-CM system,a disease or condition can be classified only in ____ location(s).
A)one
B)two
C)three
D)four
Answer: A
Q2) Coded data are used for ____.
A)reimbursement/payment
B)the study of anatomy and physiology
C)determining lab ranges
D)developing a nomenclature
Answer: A
Q3) Coded data are used for various purposes.List three of these purposes.
Answer: Coded data are used to purchase more equipment,add an operating room,hire additional staff,or gain additional skills,or for reimbursement purposes,risk management,quality improvement,or nursing clinical pathways.
Q4) WHO stands for __________.
Answer: World Health Organization
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Chapter 2: The Health Record As the Foundation of Coding
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42 Flashcards
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Sample Questions
Q1) Which of these is NOT considered a physician?
A)Internist
B)Hospitalist
C)Resident
D)Medical student
Answer: D
Q2) In some cases a patient is ready to be discharged from the hospital,but at the last minute the patient develops a condition that requires him or her to stay an additional night.An example of when a patient might have to stay an additional night is when the patient ____.
A)is feeling better
B)has no pain
C)has no additional cough
D)develops a fever
Answer: D
Q3) Principal diagnosis is one of the most important concepts for coders to understand and apply.
A)True
B)False Answer: True
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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 word(s)"____" should be interpreted to mean either "and" or "or" when it appears in the title.
A)with
B)see
C)omit code
D)and
Answer: D
Q2) What does NEC stand for?
Answer: Not elsewhere classifiable
Q3) In ICD-10-CM the final character of a code assignment can never be a letter.
A)True
B)False
Answer: False
Q4) An "Excludes1 note" under a code indicates that the terms excluded from the code are to be coded elsewhere.
A)True
B)False
Answer: True
Q5) Why is it important for the coder to understand coding conventions?
Answer: Ensures accurate assignment and sequencing of codes
Page 5
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Chapter 4: Basic Steps of Coding
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Sample Questions
Q1) What is the main term in "calculus of the ureter"?
Q2) 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
Q3) What is the main term in "rheumatoid arthritis"?
Q4) A coder must always remember that,once a term is located in the Alphabetic Index,the code must be verified in the Tabular List.
A)True
B)False
Q5) What is the subterm in "infantile eczema"?
Q6) What is the main term in "infantile eczema"?
Q7) What is the main term in "esophageal reflux"?
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Chapter 5: General Coding Guidelines for Diagnosis
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Sample Questions
Q1) In the inpatient setting,it is not acceptable to code diagnoses that have not yet been confirmed and are questionable or suspected.
A)True
B)False
Q2) What is the diagnosis code(s)for memory deficit due to previous cerebral infarction?
Q3) What is the diagnosis code(s)for acute and chronic cholecystitis?
Q4) What is the diagnosis code(s)for acute and chronic bronchitis?
Q5) What is the diagnosis code(s)for posttraumatic osteoarthritis due to previous left femoral neck fracture (hip)?
Q6) What is the diagnosis code(s)for acute and chronic renal failure?
Q7) A(n)____ is a residual effect (condition produced)after the acute phase of an illness or injury has terminated.
A)combination effect
B)acute effect
C)sequela
D)chronic effect
Q8) What is the diagnosis code(s)for acute and chronic respiratory failure?
Page 7
Q9) What are the diagnosis code(s)for acute and chronic pancreatitis?
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Chapter 6: Introduction to ICD-10-PCS
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Sample Questions
Q1) Completely closing an orifice or lumen of a tubular body part is called ____.
A)bypass
B)restriction
C)dilation
D)occlusion
Q2) Uses an endoscopic instrument to examine and perform closed procedures within a joint
A)Thoracoscopic approach
B)Arthroscopic approach
C)Laparoscopic approach
D)Endoscopic approach
Q3) Freeing a body part from an abnormal physical constraint is called ____.
A)reposition
B)division
C)release
D)transfer
Q4) A device is coded only if the device remains after the procedure is completed.
A)True
B)False
Q5) Open excisional biopsies of liver and pancreas
Page 8
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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) The first character value for a mental health procedure is G.
A)True
B)False
Q2) The seventh character identifies whether the procedure is a physical rehabilitation procedure or a diagnostic audiology procedure.
A)True
B)False
Q3) Diagnostic ultrasound right breast
Q4) CPAP,48 hours
Q5) Detoxification services are a procedure that can be coded in the mental health section.
A)True
B)False
Q6) The first character value for a physical rehabilitation or diagnostic audiology procedure is I.
A)True
B)False
Q8) Instruction of caregiver to assist patient with showering Page 9
Q7) Robotic-assisted laparoscopic abdominal hysterectomy
Q9) Removal of sutures from abdominal wall
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Page 10
Chapter 8: Coding Medical and Surgical Procedures
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Sample Questions
Q1) Ureteroscopy that was unsuccessful for stone removal,left ureter
Q2) When a patient shows up to have a procedure performed,but the procedure is canceled for whatever reason,the principal diagnosis would be
Q3) Laparoscopic Nissen fundoplication
Q4) When a diagnostic procedure is performed for the principal diagnosis and a procedure for definitive treatment is performed for a secondary diagnosis,the procedure for diagnostic treatment is the principal procedure.
A)True
B)False
Q5) Moving all or a portion of a body part to its normal location or other suitable location is called ____.
Q6) Laparoscopic cholecystectomy converted to open cholecystectomy
Q7) Nonexcisional debridement of skin-right foot ulcer
Q8) Completely closing an orifice or lumen of a tubular body part is called ____.
Q9) Bilateral fallopian tubal occlusion with Falope ring device,laparoscopic approach
Q10) Percutaneous aspiration of left perirenal abscess
Q12) Therapeutic paracentesis of peritoneal cavity,percutaneous Page 11
Q11) Cutting out or off,without replacement,a portion of a body part is called ____.
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Chapter 9: Symptoms,
signs, and
Abnormal
Clinical and Laboratory Findings Not Elsewhere Classified, and Z Codes
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Sample Questions
Q1) Outpatient Encounter: Patient has been taking Lipitor for hypercholesterolemia for 1 year.A hepatic function laboratory test was performed to assess any adverse effects on the patient's liver function.A fasting lipid profile was also done to assess the effectiveness of the Lipitor.
A)Z51.81,Z79.899,E78.00
B)E78.1,Z51.81,Z79.899
C)Z51.89,Z79.810,E78.01
D)E78.00,Z79.891
Q2) Screening for osteoporosis: __________
Q3) Another name for the coma scale is ______________ coma score.
Q4) Patient is admitted to hospice care for treatment of terminal ESRD.
A)N18.6,Z51.5
B)N18.6,Z51.89
C)Z51.5,N18.5
D)Z51.5,N18.6,Z99.2
Q5) Principal diagnosis is documented as right upper quadrant abdominal pain due to cholecystitis versus peptic ulcer disease: __________
Q6) Positive Mantoux test: __________
Q7) Urethral discharge: __________
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Chapter 10: Certain Infectious and Parasitic Diseases
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Sample Questions
Q1) ____________________ is found as white plaques on the lips,inner cheeks,or tongue.It is seen in babies,people with cancer,and diabetics.
Q2) The patient was admitted with sepsis caused by a UTI due to Escherichia coli.The patient also had acute kidney injury due to sepsis.Discharge summary states sepsis due to Escherichia coli.
A)N39.0,A45.51,N17.9,R65.20
B)A41.51,N39.0,R65.20,N17.9
C)R65.21,N39.0,A41.51,N17.9
D)A41.9,N39.0,N17.9,R65.10
Q3) Jock itch is coded to ____.
A)B35.9
B)B35.8
C)B35.6
D)B35.4
Q4) According to the discharge summary,a patient is admitted with bacterial pneumonia.Three days after admission,the patient spikes a fever and is tachycardic with a WBC of 18,000.Physician documents that the blood cultures confirm staphylococcal sepsis.
Q5) Category B20 is assigned for ____________________.
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Chapter 11: Neoplasms
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Sample Questions
Q1) Pancytopenia due to myelodysplastic syndrome: __________
Q2) Ovarian (left)malignancy with malignant ascites.Diagnostic paracentesis was performed and confirmed the malignant ascites.
A)R18.0,Z85.43,0W9G30Z
B)R18.0,C56.2,0W9G3ZX
C)C56.1,R18.8,0W9G3ZZ
D)C56.2,R18.0,0W9G3ZX
Q3) What is the abbreviation for non-small-cell lung cancer?
Q4) All of the following are considered by the National Cancer Institute to be the most common sites for cancer in the United States EXCEPT ____.
A)breast
B)lung
C)brain
D)skin
Q5) The administration of cancer-killing drugs is called ____________________.
Q6) Benign neoplasm of Cowper's gland: __________
Q7) Primary cancer of the cauda equina: __________
Q8) What is the abbreviation for small-cell lung cancer?
Q9) Glossopalatine fold carcinoma: __________
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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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Sample Questions
Q1) A patient's own blood sometimes donated before an elective surgery in case (s)he needs a transfusion
A)Apheresis
B)Blood
C)Autologous transfusion
D)5000 to 10,000/mm³
E)Hemoglobin (HGB)
F)Purpura
G)Idiopathic
H)Hematocrit (Hct)
I)Bone marrow biopsy
J)WBC
K)Secondary thrombocytopenia
Q2) Hemophilia ____,also called Christmas disease,is the result of a deficiency of factor IX.
A)A
B)B
C)C
D)D
Page 16
Q3) Patient has anemia,thrombocytopenia,and neutropenia: __________
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Page 17
Chapter 13: Endocrine, nutritional, and Metabolic Diseases
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Sample Questions
Q1) An adult patient is admitted for gastric banding procedure for treatment of morbid obesity.Patient has been obese most of her adult life and has failed all attempts at supervised diet;she has a BMI of 41.3.Patient has a family history of diabetes.She hopes to see improvement in her type 2 diabetes,with expected weight loss for bariatric surgery.Patient undergoes a laparoscopic bypass with Roux-en-Y limb to jejunum and is put on the bariatric diet,which she tolerates without difficulty.She is discharged in satisfactory condition.
Discharge Diagnosis: Morbid obesity. Diabetes.
Procedure: Laparoscopic gastric bypass.
A)E66.01,E13.9,Z68.41,Z83.3,0D164ZA
B)E66.8,E11.9,Z68.41,0D160ZA
C)E66.1,E11.8,Z68.41,Z83.3,0D168ZA
D)E66.01,E11.9,Z68.41,Z83.3,0D164ZA
Q2) A patient is admitted with hyperkalemia.What drug could be given to treat this condition?
A)K-Dur
B)Synthroid
C)Tapazole
D)Kayexalate
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Page 18
Chapter 14: Mental, behavioral, and Neuro developmental Disorders
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Sample Questions
Q1) Patient was admitted because of aggressive behavior and wandering.Neurology diagnosed dementia due to Lewy bodies.
A)G31.83,F03.91,Z91.83
B)F03.91,G31.82
C)F02.81,G31.83
D)G31.83,F02.81,Z91.83
Q2) A patient is admitted to the hospital for confusion.According to the family,the patient has been more difficult to manage at home and no longer is able to care for himself.The patient has known Alzheimer's disease.No medical cause could be determined for the patient's increasing confusion,and it is believed that nursing home placement is appropriate.
Discharge Diagnosis: Alzheimer's dementia.
A)G30.9,F03
B)F02.80,G30.9
C)G30.9,F02.80
D)G30.8,F02.80
Q3) What are the two most common mood disorders?
Q4) Stress can be a contributing factor in mental disorders.
A)True B)False
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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) A patient with known metastatic cancer to the ribs is admitted for pain control.The patient has a history of lung cancer,which was surgically excised.The patient is administered fentanyl.
A)C79.51,G89.3,Z85.118
B)G89.3,C79.51,Z85.118
C)C79.51,G89.3,C34.90
D)G89.3,G89.3,C34.90
Q2) Disorder of the optic nerve resulting in vision loss
A)Glaucoma
B)Hydrocephalus
C)Meningitis
D)Epilepsy
E)Parkinson's disease
F)Cataract
G)Cholesteatoma
H)Mastoiditis
I)Myasthenia gravis
J)Alzheimer's disease
Q3) Spastic retinal artery: __________
Q4) A(n)____________________ is a device that is used to treat intractable Page 20
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Page 21
Chapter 16: Diseases of the Circulatory System
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Sample Questions
Q1) Anterolateral myocardial infarct,initial visit: __________
Q2) Acute myocardial infarction,commonly referred to as a(n)____________________,occurs when there is complete blockage of blood flow in a coronary artery.
Q3) A patient is admitted with chest pain and is ruled in for an NSTEMI.The patient has a history of a CABG and PTCA with stent placement.Patient is taking medications for hypertension,CAD,and CHF.
A)I22.2,I25.119,I11.9,150.9,Z95.1,A95.5
B)R07.9,I21.4,I25.10,I10,I50.30,Z95.1,Z95.5
C)I21.4,I11.9,I25.10,786.50,I50.9,Z95.1,Z95.5
D)I21.4,I10,I25.10,I50.9,Z95.1,Z95.5
Q4) Family history of stroke
A)Z82.3
B)Z94.1
C)Z95.811
D)Z95.9
E)Z76.82
Q5) Prinzmetal angina: __________
Q6) AF is the abbreviation for ____________________.
Q7) What is the function of the heart?
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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.
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) Suspected H1N1 influenza: __________
Q3) ____________________ is a chronic lung disease that can result from other infections or,most commonly,cigarette smoke.
Q4) The correct abbreviation for bronchoalveolar lavage is ____________________.
Q5) What is the major organ of the respiratory system?
Q6) Eosinophilic asthma: __________
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Chapter 18: Diseases of the Digestive System
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Sample Questions
Q1) What is mastication?
Q2) ____ is the abnormal condition of stones in the gallbladder.
A)Cholecystitis
B)Choledocholithiasis
C)Cholelithiasis
D)Appendicitis
Q3) Diverticulosis: __________
Q4) Surgical treatment for gastroesophageal reflux disease
A)Nissen fundoplication
B)Herniorrhaphy
C)Appendectomy
D)Colostomy
E)Lysis of adhesions
F)PEG (percutaneous endoscopic gastrostomy)
G)TIPS (transjugular intrahepatic portosystemic shunt)procedure
H)Whipple procedure
Q5) Mallory-Weiss tear is a name for a(n)____________________ laceration of the esophagogastric junction,usually after severe vomiting.
Q6) Retrocecal abscess: __________
Q7) What happens to food once it arrives in the stomach?
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Chapter 19: Diseases of the Skin and Subcutaneous Tissue
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Sample Questions
Q1) How is cellulitis treated?
Q2) The assignment of the code for unstageable pressure ulcer should be based on clinical documentation.
A)True
B)False
Q3) What usually causes hives?
Q4) In ICD-10-CM,decubitus ulcers use a combination code for location and stage.
A)True
B)False
Q5) Senile dermatosis: __________
Q6) A patient is admitted from the nursing home with suspected aspiration pneumonia.The attending physician documents that the patient has pressure ulcers on both buttocks.The left side has a stage 2 ulcer,and the right side has a stage 1 ulcer.
A)J69.0,L89.322,L89.311
B)J18.9,L89.301,L89.319
C)J18.9,L98.419
D)J69.0,L98.411,L98.412
Q7) The organism responsible for a furuncle is Staphylococcus,which enters the body through ____________________.
Page 25
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Chapter 20: Diseases of the Musculoskeletal System and Connective Tissue
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Sample Questions
Q1) ____________________ affects children,usually between the ages of 2 and 5 years;it may affect only a few joints or many joints in the body.
Q2) Alendronate,calcitonin,and calcium with vitamin D are common medications used to treat osteoporosis.
A)True
B)False
Q3) What is the correct abbreviation for dual-energy X-ray absorptiometry?
Q4) What does the abbreviation SLE stand for?
Q5) Ball joints are small stabilizing joints located between and behind adjacent vertebrae.
A)True
B)False
Q6) ____ is one of the most common diseases affecting the muscles;it is characterized by widespread muscle pain associated with chronic fatigue.
A)Postlaminectomy syndrome
B)Bursitis
C)Fibromyalgia
D)Rhabdomyolysis
Q7) Right plantar fasciitis (right): __________
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Chapter 21: Diseases of the Genitourinary System
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Sample Questions
Q1) GN stands for ____________________.
Q2) Patient was seen in the ER with left flank pain.Discharge diagnosis is stone,left kidney.
A)N20.0,N23
B)N20.0
C)R10.9
D)N23
Q3) Hypotonic bladder: __________
Q4) Inflammation of the uterus
A)Urolithiasis
B)Nephrotic syndrome
C)Fistula
D)Prostatitis
E)Urinary tract infections (UTIs)
F)Hemodialysis
G)Endometritis
H)Renal colic
I)Mastitis
J)Acute renal failure
Q5) List one reason a breast biopsy would be performed.
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Chapter 22: Pregnancy, childbirth, and the Puerperium
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Q1) A type of abortion with fetal demise before 20 weeks but no products of conception are expelled is a(n)______________ abortion.
Q2) Ectopic pregnancies occur in 1 in ____ pregnancies.
A)10
B)25
C)50
D)100
Q3) In ICD-10-CM the final character indicates the episode of care.
A)True
B)False
Q4) Suppressed lactation postpartum: __________
Q5) A 40-week primigravida patient comes to the hospital in labor.Labor progresses,and she delivers a normal 7.6-pound infant.An episiotomy is performed and repaired.The patient had a UTI during the fourth month of pregnancy that was treated with antibiotics.She suffered from hyperemesis gravidarum early in the pregnancy.She is discharged on day 2 with no complaints.What codes are applicable? __________
Q6) In referring to a pregnant woman,what does antepartum mean?
Q7) The process of milk production is ______________________.
Q8) A term that means before delivery is _____________________.
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Chapter 23: Certain Conditions Originating in the Perinatal
Period and Congenital Malformations, deformations, and
Chromosomal Abnormalities
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Sample Questions
Q1) Newborn is delivered vaginally.The baby was premature at 34 3/7 weeks and weighed 1842 grams.Meconium staining was noted at delivery.
A)Z38.00,P96.83,P07.16,P07.32
B)P07.17,P24.00,A38.00,P07.32
C)Z38.00,P07.17,P07.37,P96.83
D)Z37.0,P03.82,P07.17,P07.32
Q2) A baby is born via C-section.Apgars are 5 at 1 minute and 7 at 5 minutes.Because of the mother's fever during labor,sepsis workup is performed.Antibiotics are discontinued when cultures return negative and sepsis is ruled out.What codes are applicable?
Q3) Congenital conditions are always present,well defined,and diagnosed at birth.
A)True
B)False
Q4) In most cases,pregnancies with chromosomal anomalies end with a natural miscarriage.
A)True
B)False
Q6) Congenital pigeon chest: __________ Page 29
Q5) For coding purposes,what is the perinatal period considered?
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Page 30
Chapter 24: Injuries and Certain Other Consequences of
External Cases and External Causes of Morbidity
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Sample Questions
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) Which of the following would NOT be an upper limb fracture?
A)A fracture to the shoulder
B)A fracture to the femur
C)A fracture to the clavicle
D)A fracture to the upper humerus
Q3) A patient is admitted with a parietal bone fracture and fracture of the left fifth rib.Assign only the injury code.
A)S02.0xxA,S22.31xA
B)S02.0xxA,S22.32xA
C)S22.32xA,S02.0xxA
D)S22.31xA,S02.0xxA
Q4) An injury to the brain that results from a significant blow to the head is called a(n)____________________.
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Chapter 25: Burns, Adverse Effects, and Poisonings
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Sample Questions
Q1) Sunburned chest: __________
Q2) Allergy other than to medicinal agents-peanuts
A)Z69.020
B)Z88.8
C)Z91.030
D)Z88.7
E)Z91.010
F)Z91.89
G)Z91.011
H)Z91.410
Q3) Debridement is one of the most common procedures performed on burn victims.
A)True
B)False
Q4) Deep necrosis of underlying tissues
A)First-degree
B)Second-degree
C)Third-degree
D)Fourth-degree
Q5) Battered spouse syndrome: Confirmed abuse by her husband: __________
Q6) What are the four major types of abuse?
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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/43725
Sample Questions
Q1) Leaking silicone breast implant,initial visit: __________
Q2) Mechanical complication of gastrostomy: __________
Q3) Mechanical complications are related to ____________________ malfunctions.
Q4) Occurs when the fracture fragments have united but are not properly aligned.
A)Malunion
B)Nonunion
C)Neuroma
D)Extravasation
E)Contracture
F)Necrosis
Q5) Leakage of infused substance into vasculature or subcutaneous tissue
A)Malunion
B)Nonunion
C)Neuroma
D)Extravasation
E)Contracture
F)Necrosis
Q6) Can code Z94.0 and a T86.1- code be used together?
Q7) What are some examples of procedures resulting in complications that occur during medical care and not during surgery?
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