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Introduction to Medical Coding offers students an overview of the essential concepts and practices in the field of medical coding. The course covers the basics of healthcare documentation, the use of standardized code sets such as ICD, CPT, and HCPCS, and the principles of translating medical diagnoses and procedures into universally recognized codes. Students will learn about the role of coding in healthcare reimbursement, compliance, and data management, and acquire foundational skills for accurate and ethical coding in a variety of healthcare settings. This course serves as a stepping stone for further study and certification in medical coding and 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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47 Verified Questions
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Sample Questions
Q1) CCS-P stands for Certified Coding Specialist-Pediatric Based.
A)True
B)False
Answer: False
Q2) Nomenclature of diseases was first developed in the United States around ____.
A)1893
B)1958
C)1928
D)1898
Answer: C
Q3) Without the __________ system the comparison of data would be impossible. Answer: classification
Q4) The ____ Bills of Mortality in the 17th century was the first attempt to statistically gather data on disease.
A)Paris
B)London
C)France
D)England Answer: B
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Sample Questions
Q1) Consultations
A)Accredits and certifies healthcare organizations
B)The problem in the patient's own words
C)The approach the practitioner is taking to solve the patient's problem
D)The condition established after study to be chiefly responsible for occasioning the admission of the patient to the hospital for care
E)Codes reported on health insurance claim forms that should be supported by documentation in the medical record
F)Person qualified by education and legally authorized to practice medicine
G)Requested by the attending physician to gain an expert opinion on the treatment of a particular aspect of the patient's condition that is outside the expertise of the attending physician
H)People who treat patients
I)The physician identifies the history,physical examination,and diagnostic tests
J)Where the subjective and objective combine for conclusion
K)Words of the patient;the reason the patient has presented to a healthcare facility for treatment
Answer: G
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Sample Questions
Q1) The bolded subterm in the diagnostic statement poorly controlled diabetes is a(n)____ modifier.
A)essential
B)nonessential
Answer: A
Q2) What does CPT stand for?
A)Coding Principals Together
B)Current Practice Theory
C)Chapter Procedure Theory
D)Current Procedural Terminology
Answer: D
Q3) "__________" is used in the Alphabetic Index to provide guidance when two conditions are related or have a causal relationship.
Answer: Due to or with
Q4) The term "with" in the code title requires documentation of what?
Answer: That both conditions linked by the term "with" must be present and documented for this code to be assigned
Q5) What does NEC stand for?
Answer: Not elsewhere classifiable
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35 Flashcards
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Sample Questions
Q1) The main term is ____.
A)always identified in italics
B)a review of the patient's hospital course
C)a term identifying disease conditions or injuries
D)a word found in parentheses that enclose explanatory information that does NOT affect the code
Q2) What is the subterm in "rheumatoid arthritis"?
Q3) Once a code has been selected from the Alphabetic Index,it must be verified in this
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
Q4) What is the subterm in "esophageal reflux"?
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Sample Questions
Q1) 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
Q2) The selection of codes A00.0 through Z99.89 will NOT be used frequently to describe the reason for the admission/encounter.
A)True
B)False
Q3) A patient who is a known diabetic is admitted for treatment of an ulcer of the left great toe.What is the principal diagnosis?
Q4) A patient is admitted to the hospital with vomiting,diarrhea,and an inability to eat or drink.IV fluids are administered,and the patient is put on bowel rest.The following day the patient is discharged with a diagnosis of gastroenteritis and dehydration.What is the principal diagnosis?
Q5) What is the diagnosis code(s)for memory deficit due to previous cerebral infarction?
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Sample Questions
Q1) The first character of an ICD-10-PCS code represents ____.
A)body part
B)approach
C)section
D)device
Q2) ____________________ is a minimally invasive technique that uses robotic arms to manipulate the surgical equipment and tools.
Q3) Uses an endoscopic instrument to examine and perform closed procedures within the thorax
A)Thoracoscopic approach
B)Arthroscopic approach
C)Laparoscopic approach
D)Endoscopic approach
Q4) The resection of tonsils is coded to an external approach.
A)True
B)False
Q5) Open partial nephrectomy,left
Q6) Body systems designated as "upper" contain body parts above the heart.
A)True
B)False
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Sample Questions
Q1) The fourth character is the body part that is the focus of the radiation therapy.
A)True
B)False
Q2) Ultrasound pediatric heart,transesophageal
Q3) Root type is the sixth character in the physical rehabilitation and diagnostic audiology section.
A)True
B)False
Q4) Measurement is defined as determining the level of physiological or physical function repetitively over a period of time.
A)True
B)False
Q5) In the Administration section,character "6" is used to identify the substance being introduced.
A)True
B)False
Q6) CT procedures are located in the nuclear medicine section.
A)True
B)False
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66 Verified Questions
66 Flashcards
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Sample Questions
Q1) Closed reduction of right radial fracture
Q2) Root operation to remove some/all of a body part
A)Drainage
B)Excision
C)Occlusion
D)Release
E)Removal
F)Reposition
Q3) Completely closing an orifice or lumen of a tubular body part is called ____.
Q4) Left kidney transplant,cadaver donor
Q5) Placement of central venous catheter with the tip at the cavoatrial junction
Q6) 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
Q7) Frenulotomy for treatment of ankyloglossia
Q8) Percutaneous repositioning of dislocated atrial pacemaker lead
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Sample Questions
Q1) The patient was admitted for biopsy of an enlarged lymph node in the area of the left axilla.The patient has a past medical history of breast cancer with a mastectomy of the left breast 1 year ago.The patient is no longer receiving any therapy for her cancer.A needle biopsy was done.The pathology report showed normal lymphatic tissue with no evidence of metastatic spread.
Final Diagnosis: Lymphadenopathy left axilla;metastasis ruled out.
Procedure: Needle core biopsy axillary lymph node.
A)R59.9,Z85.3,Z90.12,07B63ZX
B)R59.1,Z85.3,Z90.12,07B63ZZ
C)R59.0,Z85.3,Z90.11,07B53ZX
D)R59.0,Z85.3,Z90.12,07B63ZX
Q2) Gas pain: __________
Q3) Patient was seen in the clinic.Final diagnosis is RUQ rebound abdominal tenderness.
A)R10.11
B)R10.811
C)R10.821
D)R10.829
Q4) What is meant by screening examination or test?
Q5) Screening for sickle cell disorder: __________
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Sample Questions
Q1) Assign the code for suspected carrier of group B strep.
Q2) Patient has elevated liver function tests and was diagnosed with viral hepatitis C.
A)B19.20
B)B19.21
C)B19.9
D)B19.20,R79.89
Q3) The systemic inflammatory response to infection or trauma;includes fevers,tachycardia,and leukocytosis
A)SIRS
B)Bacteremia
C)Septicemia
D)Gonorrhea
E)Septic shock
F)Sepsis
Q4) Of the following medications,which is NOT an antifungal medication?
A)Nizoral
B)Grisactin
C)Lotrimin
D)Zovirax
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Sample Questions
Q1) What drug could be given to treat anemia due to malignancy?
A)Nolvadex
B)Neupogen
C)Neulasta
D)Epogen
Q2) Glossopalatine fold carcinoma: __________
Q3) A patient has a malignancy in the right upper outer quadrant of the breast.There is another primary malignancy in the right lower outer quadrant.She will be scheduled for a mastectomy soon.
A)C50.421,C50.422
B)C50.411,C50.511
C)C50.811
D)C50.821,C79.81
Q4) Neoplasms can affect ONLY certain specific body systems.
A)True
B)False
Q5) CDC stands for ____________________.
Q6) Preventive or ____________________ surgery is performed to remove tissue that has the potential to become cancerous.
Q7) What is the abbreviation for non-small-cell lung cancer?
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Mechanism
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Sample Questions
Q1) SCID stands for ____________________.
Q2) A patient was seen in the clinic for desquamation of skin.He had a bone marrow transplant 2 months ago.The physician is treating him for acute graft versus host disease.
A)T86.01,D89.811
B)T86.09,D89.813
C)T86.09,D89.810,R23.4
D)T86.01,D89.810,R23.4
Q3) All of the following are symptoms of anemia EXCEPT ____.
A)hot flashes
B)numbness and tingling sensations
C)headaches
D)brittle nails
Q4) What are two reasons for iron deficiency?
Q5) Thrombocytopenia due to chronic alcoholism: __________
Page 14
Q6) ____ are medications that are used to prevent venous thrombi.
A)Antiplatelets
B)Anticonvulsant
C)Antidoted.
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68 Flashcards
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Sample Questions
Q1) The ____ regulates metabolism of glucose in body cells and maintains proper blood glucose.
A)thymus
B)pancreas
C)pineal gland
D)adrenal medulla
Q2) What is exophthalmos?
Q3) Replacement therapy with calcium and vitamin D
A)Vitamin deficiencies
B)Malnutrition
C)Obesity
D)Diabetes
E)Hyperkalemia
F)Cystic fibrosis
G)Hypoparathyroidism
Q4) Fluid overload: __________
Q5) Iritis right eye due to diabetes,type 2,out of control: __________
Q6) Familial hypercholesterolemia: __________
Q7) DKA in patient with uncontrolled type 1 diabetes: __________
Q8) Hypoglycemia: __________
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Sample Questions
Q1) An adult female patient is admitted for treatment of anorexia nervosa.The patient has moderate malnutrition,severe electrolyte imbalance,and nutritional cardiomyopathy.The dietitian documents a BMI of 18.
A)F50.00,E44.0 E87.8,I43,Z68.1
B)E44.0,F50.00,E87.8,I43
C)E87.8,F50.02,E44.0,I43,Z68.1
D)F50.01,E44.1,E87.8,I43
Q2) Asexual transsexualism: __________
Q3) What cognitive impairments can be caused by dementia?
Q4) Drug withdrawal treatment depends on the drug from which a person is having withdrawal.
A)True
B)False
Q5) Name one occurrence during birth that can cause intellectual disability.
Q6) Homicidal ideation: __________
Q7) ____________________ is a progressive deterioration of mental faculties characterized by impairment of memory and one or more cognitive impairments.
Q8) AIDS-related dementia: __________
Q9) Active Heller's syndrome: __________ Page 17
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Sample Questions
Q1) What does the abbreviation "sz" stand for?
Q2) Patient comes to the ER with high fever and headache.Meningitis is suspected.A lumbar puncture is performed and reveals bacterial meningitis.
A)G00.8,009Y00X
B)G00.8,009Y0ZX
C)G00.9,R51,R50.9,009U3ZX
D)G00.9,009U3ZX
Q3) A patient with trigeminal neuralgia and a history of migraine headaches is admitted for an open rhizotomy.A day after the procedure,the patient develops a severe headache diagnosed as a migraine.
A)G50.0,G43.901,008M3ZZ
B)G50.0,G43.909,008K0ZZ
C)G50.0,G43.901,008K0ZZ
D)G50.0,G43.909,008K4ZZ
Q4) There are no vaccines to prevent meningitis caused by Streptococcus pneumoniae.
A)True
B)False
Q6) Amaurosis: __________ Page 19
Q5) Mastoid cholesteatoma of the right ear: __________
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Sample Questions
Q1) Diuretics: Aldactone;beta blockers: atenolol,Vasotec,Cozaar,Calan,Cardizem,and
Aldomet
A)Angina
B)Atrial fibrillation
C)Congestive heart failure
D)Hypertension
Q2) Inflammation of the covering of the heart
A)Transient ischemic attack
B)Atherosclerosis
C)Aneurysm
D)Pericarditis
E)Endocarditis
F)Cardiomyopathy
G)Conduction disorder
H)Diagnostic cardiac catheterization
Q3) Atherectomy is the removal of plaque from the vessel.
A)True
B)False
Q4) Sick sinus syndrome: __________
Q5) Stenosis of bilateral carotid arteries: __________
21
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Sample Questions
Q1) Escherichia coli pneumonia: __________
Q2) Laryngeal spasm: __________
Q3) The ____________________system's primary function is to supply the body with oxygen.
Q4) It is inappropriate for coders to assume a causal organism based on laboratory or radiology findings alone.
A)True
B)False
Q5) Personal history of malignant neoplasm-nasal cavities,middle ear,and accessory sinuses
A)Z82.5
B)Z83.6
C)Z87.891
D)Z85.22
E)Z48.24
F)Z77.090
G)Z93.0
Q6) Asthmatic bronchitis: __________
Q7) What is the major organ of the respiratory system?
22
Q8) Acute bronchiolitis due to RSV: __________
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Sample Questions
Q1) Which of the following esophageal conditions is most commonly treated with Prilosec?
A)Esophageal hemorrhage
B)Mallory-Weiss tear
C)Diverticulitis
D)Esophageal reflux
Q2) The ER physician documents that the patient is being admitted for hematemesis.The patient has an Hct of 24.3.A transfusion of packed red blood cells is administered (via peripheral vein),and the patient is taken to the OR for an EGD.The EGD reveals that the patient has an acute perforated duodenal ulcer that is causing the bleed.The ulcer is cauterized.The patient is treated with IV antibiotics,omeprazole,and NG tube.The discharge summary lists an additional diagnosis of acute blood loss anemia.
A)D62,K26.2,0D597ZZ,30233N1
B)K26.2,D62,0D598ZZ,30233N1
C)D62,K26.1,0D597ZZ,30233P0
D)K26.1,D62,0D598ZZ,30233P1
Q3) Assign the code for hematemesis: __________
Q4) What is mastication?
Q5) Name one purpose of the small intestine.
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57 Flashcards
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Sample Questions
Q1) Patient stepped on a piece of glass and injured his foot 2 days ago.There is a laceration of the left foot.No foreign body was present.He is now being admitted to the hospital for treatment of cellulitis in the left leg.
A)L03.115,W25xxxA
B)S91.312S
C)S91.312A,W25xxxA
D)L03.116,S91.312A,W25.xxxA
Q2) Senile dermatosis: __________
Q3) Nail horn,left thumb: __________
Q4) When dermatitis is caused by contact with a substance,it is called ____ dermatitis.
A)exogenous
B)endogenous
C)mesogenous
D)outer contact
Q5) Asteatosis cutis: __________
Q6) The skin is composed of ____________________ layers.
Q7) Skin grafts can be only full-thickness skin grafts.
A)True
B)False

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Sample Questions
Q1) Myelopathy is compression of the ____________________.
Q2) Alendronate,calcitonin,and calcium with vitamin D are common medications used to treat osteoporosis.
A)True
B)False
Q3) Spinal stenosis is the widening or rupture of the spinal canal.
A)True
B)False
Q4) Arthroscopic surgery is a highly invasive surgery that involves the use of instruments to perform surgery through very large incisions.
A)True
B)False
Q5) Ankylosis of right shoulder: __________
Q6) Subacute osteomyelitis of sacrum with decubitus sacral ulcer,stage
3.Staphylococcus aureus is the causative organism.
A)M46.28,L89.153,B95.61
B)M46.28,L89.153,B95.62
C)B95.61,M46.28,L89.153
D)M46.27,L89.152,B95.62
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Sample Questions
Q1) ICD-10-CM classifies chronic kidney disease based on severity.
A)True
B)False
Q2) GN stands for ____________________.
Q3) Patient was admitted for TURP (partial prostatectomy via endoscope)for BPH with urinary obstruction.
A)N13.8,N40.0,0VT07ZZ
B)N40.1,N13.8,0VB08ZZ
C)N40.0,0VB08ZZ
D)N40.3,N13.8,0VB07ZZ
Q4) Cancer of the prostate with radical prostatectomy (including bilateral seminal vesicles)with bilateral regional pelvic lymphadenectomy (diagnostic sampling).
A)D29.1,0VT00ZZ,0VT30ZZ,07BC0ZZ
B)D29.8,0VT04ZZ,0VTC4ZZ,07BC4ZZ
C)C63.7,0VT04ZZ,0VTC4ZZ,07BC4ZX
D)C61,0VT00ZZ,0VT30ZZ,07BC0ZX
Q5) A patient is admitted with hematuria and renal colic.Renal ultrasound shows a UPJ stone with left hydronephrosis.ESWL on the left ureter was performed.Patient has a history of UTIs and Parkinson's disease.__________
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Sample Questions
Q1) Younger than 16 at date of delivery
A)Young obstetric patient
B)Antepartum
C)Primigravida
D)Puerperium
E)Gravid
F)Elderly OB patient
Q2) First pregnancy
A)Young obstetric patient
B)Antepartum
C)Primigravida
D)Puerperium
E)Gravid
F)Elderly OB patient
Q3) Lupus nephritis in second trimester of pregnancy (20 weeks): __________
Q4) Cephalopelvic disproportion as cause of obstruction delivered single-term (40 weeks)liveborn via classical C-section this admit: __________
Q5) Gestational edema,second trimester antepartum (25 weeks): __________
Q6) Acute gonococcal cervicitis in the second trimester of pregnancy (26 weeks):

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Sample Questions
Q1) ____________________ involves problems of the mouth and oral cavity.It may require several reconstructive surgeries after the baby is at least 10 weeks old and weighs at least 10 pounds.
Q2) An infant is born by cesarean section.On examination,the infant is noted to have neonatal teeth and a strawberry nevus on the left leg.
A)Z38.01,K00.6,Q82.5
B)Z38.00,K00.9,Q82.8
C)Z38.01,K00.9,Q82.5
D)Z38.00,K00.6,Q82.8
Q3) Prematurity is based on recorded birth weight and gestational age and documentation of prematurity.
A)True
B)False
Q4) Newborn is delivered vaginally and is ruled in for group B strep sepsis.
A)Z38.00,A41.9,R65.20,P00.2
B)Z38.01,P00.2
C)Z38.01,R65.20,A41.9
D)Z38.00,P36.0
Q5) What is a congenital anomaly? Page 28
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Sample Questions
Q1) A patient is admitted with a laceration of the forehead due to a collision with another player during a professional soccer game.On further examination,it feels as though there may be a foreign body,so the patient is taken to the OR for exploration,where the laceration was extended and a foreign body was removed from the subcutaneous tissue.The laceration of the skin was sutured.The pathology report determines the foreign body to be a tooth.
Q2) Open-fracture fifth metatarsal on the right,initial encounter: __________
Q3) 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
Q4) Patient was seen with an abrasion with laceration of the left knee,initial encounter.Assign only the injury code.
A)S81.011D
B)S81.011A
C)S81.012D
D)S81.012A
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Sample Questions
Q1) Which of the following is true when a poisoning or reaction to the improper use of medication is coded?
A)The poisoning T code is sequenced first,followed by a code for the manifestation.
B)The code for the manifestation is sequenced first,followed by the poisoning T code.
C)The poisoning T code is sequenced second,followed by a third code for the manifestation.
D)None of the above is correct.
Q2) A side effect or reaction to a drug that has been taken properly is called a(n)____________.
Q3) Patient was admitted with second-degree burns of the left hand and first-degree burns of the left forearm.The patient touched a hot steam pipe.
A)T23.202A,T22.111A,X16.xxxA
B)T23.202A,T22.112A,X16.xxxA
C)T23.202D,T22.112D,X16.xxxD
D)T22.112A,T23.202A,X16.xxxA
Q4) Active treatment of nonhealing second-degree burn to right forearm due to hot iron while ironing (accidental): __________
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Sample Questions
Q1) Patient with decreased visual acuity due to corneal graft rejection.Admitted for cadaver keratoplasty (external)of the left eye with removal of the previous corneal graft
A)T86.840,Y83.0,H54.7,08R9XKZ
B)T85.318A,Y83.0,H54.7,08R93KZ
C)T86.840,Y83.0,H54.7,08R83KZ
D)T86.841,Y83.0,H54.7,08R8XKZ
Q2) Patient was admitted for an open TAH (removal of uterus and cervix)due to symptomatic fibroids.The physician documented in the operative report that a complication had occurred in which the bladder was accidentally lacerated during the procedure and was repaired with suture.
A)D25.9,N99.72,0UT97ZZ,0UTC0ZZ,0TQB0ZZ
B)D25.9,N99.71,0UT90ZZ,0UTC0ZZ,0TQB0ZZ
C)D25.9,N99.72,0UT90ZZ,0TQB7ZZ
D)D25.9,N99.71,0UT97ZZ,0TQB7ZZ
Q3) Codes for complications may be located in the chapter for specified body sites.
A)True
B)False
Q4) Mechanical complication of gastrostomy: __________
Q5) Can code Z94.0 and a T86.1- code be used together?
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