Medical Coding and Classification Exam Bank
Course Introduction
Medical Coding and Classification introduces students to the principles, guidelines, and practices of coding procedures and diagnoses in healthcare settings. The course covers major coding systems such as ICD (International Classification of Diseases), CPT (Current Procedural Terminology), and HCPCS (Healthcare Common Procedure Coding System), focusing on accurate translation of medical documentation into standardized codes for billing, reimbursement, data analysis, and quality improvement. Students will develop skills in analyzing medical records, applying coding guidelines, and ensuring compliance with legal and ethical standards. Practical exercises and case studies prepare students for roles in healthcare administration, insurance processing, and compliance auditing.
Recommended Textbook
ICD 10 CM PCS Coding Theory and Practice 2018 Edition 1st Edition by Karla R. Lovaasen
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26 Chapters
1616 Verified Questions
1616 Flashcards
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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) Official coding advice is published in the publication ____.
A)Coding Edge
B)AHA Coding Clinic
C)Journal of the American Health Information Management Association
D)In Record Time
Answer: B
Q2) The two most well-known professional associations for coders are __________ and __________.
Answer: AHIMA; AAPC
AAPC, AHIMA
AHIMA AAPC
AAPC AHIMA
Q3) ICD-10-CM/PCS can be updated _________ times each year.
Answer: two
Q4) To maintain their credentials, coders must earn __________.
Answer: continuing education units (CEUs)
continuing education units
CEUs
Q5) Without the __________ system, the comparison of data would be impossible.
Answer: classification
3
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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) GERD
A)Centers for Medicare and Medicaid Services
B)Temperature, pulse, and respiration
C)Uniform Hospital Discharge Data Set
D)Gastroesophageal reflux disease
Answer: D
Q2) 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
Q3) It is the responsibility of a coder to extract from the health record the diagnoses and procedures for which a patient is being treated.
A)True
B)False
Answer: True
Q4) How long after admission is it required by TJC that the admission history and physical be completed?
Answer: Within 24 hours
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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) "Diseases of the skin and subcutaneous tissue (L00-L99)" represents a ____.
A)chapter
B)section
C)category
D)subcategory
Answer: A
Q2) 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
Q3) In ICD-10-CM, there is an additional index called the External Causes of Injury.
A)True
B)False Answer: True
Q4) The bolded subterm in the diagnostic statement purulent pneumonia is a(n) ____ modifier.
A)essential
B)nonessential Answer: B
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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) What is the subterm in "esophageal reflux"?
Q2) 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
Q3) What is the main term in "aspiration pneumonia"?
Q4) The __________, if available, is the first step in the process of record review for code selection.
Q5) Which of the following is a basic step in coding?
A)Review the medical record.
B)Identify main term(s) in the Alphabetic Index.
C)Assign codes to the highest level of specificity by verifying in the Tabular List.
D)All of the options are correct.
Q6) What is the main term in "rheumatoid arthritis"?
Q7) What is the subterm in "aspiration pneumonia"?
Q8) What is the main term in "esophageal reflux"?
Q9) What is the main term in "infantile eczema"?
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Chapter 5: General Coding Guidelines for Diagnosis
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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) What is/are the diagnosis code(s) for acute and chronic pancreatitis?
Q3) What is/are the diagnosis code(s) for acute and chronic cholecystitis?
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) The selection of codes A00.0 through T88.9, Z00-Z99.8 is NOT used frequently to describe the reason for the admission/encounter.
A)True
B)False
Q6) What is/are the diagnosis code(s) for thoracolumbar scoliosis (neuromuscular) due to past history of poliomyelitis?
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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) Which of the following is NOT a characteristic of ICD-10-PCS codes?
A)Codes are alphanumeric
B)Codes are seven characters.
C)Codes are expandable.
D)Codes are three to four digits.
Q2) Temporary postoperative wound drains are not considered devices, and no ICD-10-PCS code is assigned.
A)True
B)False
Q3) The spleen is in what body system?
Q4) The fifth character value represents the body part in the medical and surgical section.
A)True
B)False
Q5) The fourth character of an ICD-10-PCS code represents a(an) ____.
A)body part
B)approach
C)section
D)device
Q6) The thoracic nerve is in what body system?
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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 seventh character identifies whether the procedure is a physical rehabilitation procedure or a diagnostic audiology procedure.
A)True
B)False
Q2) Root type is the sixth character in the physical rehabilitation and diagnostic audiology section.
A)True
B)False
Q3) Hearing treatment with cerumen management in rehab
Q4) Radionuclide is root type in the nuclear medicine section. A)True
B)False
Q5) Placement of nasal packing, right nare
Q6) The first character value for substance abuse treatment is B. A)True B)False
Q7) A bone marrow transplant is coded to the root operation, transplant. A)True
B)False
Q8) Educational counseling Page 9
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Page 10
Chapter 8: Coding Medical and Surgical Procedures
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66 Verified Questions
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Sample Questions
Q1) Placement of central venous catheter with the tipat the cavoatrial junction
Q2) Visually and/or manually exploring a body part is called ____.
Q3) In some instances, a surgical wound is not closed at the time of a surgical operation and is allowed to heal and will be closed at a later date. This is an example of when a ____ would be coded.
A)closure
B)bilateral procedure
C)biopsy
D)limited coverage
Q4) Cutting off all or a portion of the upper or lower extremities is ____.
Q5) Above-knee amputation, right midshaft femoral region
Q6) Nonexcisional debridement of skin-right foot ulcer
Q7) Root operation that alters the diameter/route of a tubular body part
A)Drainage
B)Excision
C)Occlusion
D)Release
E)Removal
F)Reposition
Q8) Open thyroidectomy with removal of the entire right lobe
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Chapter 9: Symptoms,
Signs, and
Abnormal
Clinical and Laboratory Findings Not Elsewhere Classified, and Z Codes
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60 Verified Questions
60 Flashcards
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Sample Questions
Q1) 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
Q2) Counseling on the initiation of contraceptive foam use: __________
Q3) Patient is admitted with an acute cerebrovascular accident. The NIHSS score on admission is 35: _____________________________
Q4) Done in the absence of any signs or symptoms
A)A primary circumstance for using Z codes
B)Symptom
C)Screening exam
D)Is a main term in the Alphabetic Index
E)Sign
Q5) Urethral discharge: __________
Q6) Principal diagnosis is documented as right upper quadrant abdominal pain due to cholecystitis versus peptic ulcer disease: __________
Q7) Camp physical: __________
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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) Spread by sexual contact; men are more likely to have symptoms such as burning while urinating and discharge from the penis; treated with antibiotic
A)SIRS
B)Bacteremia
C)Septicemia
D)Gonorrhea
E)Septic shock
F)Sepsis
Q2) Trench mouth is coded to ____.
A)A69.0
B)A69.1
C)A27.9
D)A36.3
Q3) Assign the code for Colorado tick fever.
Q4) Z21 is a code used for patients with HIV who have no symptoms and who have never had an AIDS-defining or AIDS-related illness.
A)True
B)False
Q5) Assign the code for Ebola virus.
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Chapter 11: Neoplasms
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Sample Questions
Q1) 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
Q2) A patient was admitted with an intestinal obstruction due to peritoneal metastasis from inoperable rectosigmoid cancer.
A)C78.6, C19
B)K56.69, C19, C78.6
C)C78.6, K56.60
D)C19, C78.6
Q3) When admission is for treatment of a complication resulting from a surgical procedure, the complication should be the principal diagnosis if the treatment is directed at resolving the complication.
A)True
B)False
Q4) A patient is admitted with headache due to malignant glioblastoma multiforme. A workup is performed to evaluate the progression of the frontal lobe tumor.
Q5) Cancer of the lymphatic system is called ____________________.
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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
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Sample Questions
Q1) A(n) ____________________ is a blood test used to evaluate the patient's overall health and detects a variety of disorders.
Q2) ____________________ is an increased number of white cells in the blood.
Q3) ____________________ anemia results from abnormal or excessive destruction of red blood cells.
Q4) Sarcoidosis of the skin: ____________
Q5) Postoperative anemia: __________
Q6) Familial erythrocytosis: __________
Q7) A protein in red blood cells that carries oxygen to body tissues
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 Page 15
K)Secondary thrombocytopenia
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Page 16
Chapter 13: Endocrine, Nutritional, and Metabolic Diseases
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68 Verified Questions
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Sample Questions
Q1) Postural drainage and chest percussion treatments, pancreatic enzymes and vitamins, antibiotics for infections, and possibly lung transplant
A)Vitamin deficiencies
B)Malnutrition
C)Obesity
D)Diabetes
E)Hyperkalemia
F)Cystic fibrosis
G)Hypoparathyroidism
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) Lactic acidosis: __________
Q4) Marasmus: __________
Q5) Hypoglycemia: __________
Q6) The correct abbreviation for phenylketonuria is ____________________.
Q7) Vitamin D deficiency: __________
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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) What are the two most common mood disorders?
Q2) A 28-year-old man was brought to the ER by a friend who stated that the patient had been acting bizarrely. The patient has been irritable, pacing the apartment, and talking nonstop. He was admitted to the psychiatric unit for management of his manic symptoms.Final Diagnosis: Bipolar affective disease Severe manic phase. Recurrent episode with psychosis.
A)F31.2
B)F31.73
C)F31.74
D)F31.10
Q3) 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
Q4) Korsakoff disease due to alcohol dependence: __________
Page 18
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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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55 Verified Questions
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Sample Questions
Q1) Spastic retinal artery: __________
Q2) A patient is admitted with an acute change in mental status. Patient has a history of CHF, DM type 2, and prostate cancer. Patient had a prostatectomy 2 years PTA. Upon completion of the lab work, the physician documents metabolic encephalopathy due to urinary tract infection. Patient was treated with IV antibiotics.
A)G93.41, I50.9, E11.9, Z85.46
B)N39.0, I50.9, E11.9, Z85.46
C)G93.41, I50.9, E11.9, Z85.46.
D)N39.0, G93.41, I50.9, E11.9, Z85.46.
Q3) Growth in the middle ear that usually results from repeated ear infections
A)Glaucoma
B)Hydrocephalus
C)Meningitis
D)Epilepsy
E)Parkinson disease
F)Cataract
G)Cholesteatoma
H)Mastoiditis
I)Myasthenia gravis
J)Alzheimer disease
Page 19
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Chapter 16: Diseases of the Circulatory System
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65 Verified Questions
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Sample Questions
Q1) What is the abbreviation for congestive heart failure?
Q2) Tachycardia is an abnormally high heart rate of more than 100 beats/min.
A)True
B)False
Q3) Family history of stroke
A)Z82.3
B)Z94.1
C)Z95.811
D)Z95.9
E)Z76.82
Q4) Inflammation of the lining of the heart chambers and valves
A)Transient ischemic attack
B)Atherosclerosis
C)Aneurysm
D)Pericarditis
E)Endocarditis
F)Cardiomyopathy
G)Conduction disorder
H)Diagnostic cardiac catheterization
Q5) 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) ____________________ is a chronic lung disease that can result from other infections or, most commonly, cigarette smoke.
Q2) Idiopathic pulmonary fibrosis: __________
Q3) A 1-year-old male was admitted with barking cough, stridor, and hoarseness. The patient was up to date on all vaccinations and had achieved normal developmental milestones. Patient was treated for acute laryngotracheobronchitis and recovered.Discharge Diagnosis: Acute laryngotracheobronchitis
A)J20.9, R06.1
B)R06.1, J40
C)J41
D)J20.9
Q4) Infant was seen in the ER with diagnosis of acute bronchiolitis due to RSV. The infant has been exposed to tobacco smoke.
A)Z77.22, J21.9
B)J21.0, Z77.22
C)J21.8, B97.4
D)B97.4, J21.0
Q5) Escherichia coli pneumonia: __________
Q6) The correct abbreviation for bronchoalveolar lavage is ____________________.
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Chapter 18: Diseases of the Digestive System
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Sample Questions
Q1) The patient has a diagnosis of upper esophageal stricture and a history of COPD. An EGD with dilatation of the stricture is performed.
A)K22.4, J44.9, 0D758DZ
B)K22.2, J44.9, 0D718ZZ
C)K22.5, J44.1, 0D717DZ
D)K22.2, J44.1, 0D718ZZ
Q2) The squeezing or movement of food toward the stomach and down the digestive tract is called ____.
A)mastication
B)peristalsis
C)thrombosis
D)perforation
Q3) Assign the code for hematemesis: __________
Q4) An ileostomy is very similar to a(n) ____________________ EXCEPT that the end of the small intestine is brought through the abdominal wall.
Q5) Lingua villosa nigra: __________
Q6) Diverticulosis: __________
Q7) Assign the code for choledochoduodenal fistula: __________
Q8) Name one purpose of the small intestine.
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Chapter 19: Diseases of the Skin and Subcutaneous System
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Sample Questions
Q1) Rhinophyma: __________
Q2) What is an abscess of the skin?
Q3) Patient comes to the hospital for full-thickness skin graft to the thigh from the abdomen to repair a skin contracture from a third-degree burn of the left thigh.
A)L90.5, 0HRLX73, 0HB7XZZ
B)T24.312A, 0HRLX73
C)L90.5, 0HRKX74
D)L90.5, T24.312S, 0HRJX73, 0HB7XZZ
Q4) A(n) ____ is a skin graft from one person to another.
A)allograft
B)autograft
C)xenograft
D)mesnograft
Q5) The skin and its accessory organs are part of the ____________________ system.
Q6) What is excisional debridement?
Q7) Skin grafts can be only full-thickness skin grafts.
A)True
B)False
Q8) How is cellulitis treated?
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Chapter 20: Diseases of the Musculoskeletal System and Connective Tissue
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Sample Questions
Q1) Chondromalacia of the left patella: __________
Q2) What drug could be given to treat rheumatoid arthritis?
A)Boniva
B)Fosamax
C)Celebrex
D)Calcium
Q3) What is the correct abbreviation for dual-energy x-ray absorptiometry?
Q4) The front of the body or organ
A)Medial
B)Cranial
C)Ventral
D)Superior
E)Caudal
F)Dorsal
G)Lateral
Q5) What does the abbreviation SLE stand for?
Q6) Myelopathy is compression of the ____________________.
Q7) Necrotizing fasciitis, also called ____________________, is a rare but serious condition in which an infection occurs in the tissues below the skin. It usually is caused by group A Streptococcus. Page 25
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Chapter 21: Diseases of the Genitourinary System
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Sample Questions
Q1) Vesicoperineal fistula: __________
Q2) Male patient with intrinsic sphincter deficiency with urinary stress incontinence with insertion of artificial bladder neck sphincter via open approach: __________
Q3) Which of the following can be detected by a urinalysis test?
A)Kidney stones
B)Diabetes
C)Cystitis
D)All of the above
Q4) Ulceration of the vulva: __________
Q5) ____________________ is the presence of blood in the urine.
Q6) 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
Q7) Use of code category N18.- with Z94.0 ALWAYS indicates transplant rejection or failure.
A)True
B)False
Q8) Benign hyperplasia of the prostate with nocturia times three: __________
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Chapter 22: Pregnancy, Childbirth, and the Puerperium
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Sample Questions
Q1) If code O80 is assigned, other codes in the O00-O9A range should also be assigned, if applicable.
A)True
B)False
Q2) Before delivery
A)Young obstetric patient
B)Antepartum
C)Primigravida
D)Puerperium
E)Gravid
F)Elderly OB patient
Q3) Younger than 16 years of age at date of delivery
A)Young obstetric patient
B)Antepartum
C)Primigravida
D)Puerperium
E)Gravid
F)Elderly OB patient
Q4) What happens in a molar pregnancy?
Q5) What does it mean when a pregnant woman is called primigravida?
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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) What is the most common treatment for infants with moderate jaundice?
Q2) A congenital heart defect manifested by four key features, all involving the heart
A)Klinefelter syndrome
B)Spina bifida
C)Meckel diverticulum
D)Marfan syndrome
E)Tetralogy of Fallot
F)Down syndrome
Q3) There is no cure for Down syndrome, but the risk increases the older the mother is during her pregnancy.
A)True
B)False
Q4) Achondroplasia: __________
Q5) Cesarean delivery at term of baby; hypothermia (not environmental) noted on admit to nursery: __________
29
Q6) For coding purposes, what is the perinatal period considered?
Q7) Polydactyly fingers: __________
Q9) Cesarean delivery at term of interlocking twins, twin A: __________
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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) A closed fracture occurs when the bone exits and is visible through the skin or when a deep wound exposes the bone through the skin.
A)True
B)False
Q3) An open fracture occurs when the bone is broken but the skin remains intact.
A)True
B)False
Q4) In ICD-10-CM, if a fracture is not specified, it is coded to nondisplaced.
A)True
B)False
Q5) Where are foreign bodies most likely to enter?
Q6) Sprained left ankle, initial encounter: __________
Q7) Anaphylactic shock due to ingestion of milk: __________ Page 31
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Chapter 25: Burns, Adverse Effects, and Poisonings
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Sample Questions
Q1) Deep necrosis of underlying tissues
A)First-degree
B)Second-degree
C)Third-degree
D)Fourth-degree
Q2) The abbreviation OR stands for ____________________.
Q3) The patient was admitted with hematemesis. The patient has been taking NSAIDs as directed by the physician for arthritis pain. EGD showed that the patient had an acute erosive gastritis, most likely due to NSAIDs, which is the likely cause of the bleeding.Final Diagnosis: Erosive gastritis with hemorrhage due to NSAIDs Procedure: EGD with gastric biopsy
A)K29.01, T39.395A, M19.90, 0DB68ZX
B)T39.395A, K29.61, M19.90, 0DB78ZZ
C)T49.0x2A, K29.00, M19.90, 0DB78ZX
D)T49.0x1D, K29.71, M19.90, 0DB67ZZ
Q4) Are healthcare providers required to report suspicion of abuse to the authorities?
Q5) What are the four major types of abuse?
Q6) Battered spouse syndrome: Confirmed abuse by her husband: __________
Q7) Patient has itching due to oxycodone, which was taken as prescribed: __________
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Chapter 26: Complications of Surgical and Medical Care
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Sample Questions
Q1) A patient had a kidney transplant 2 years ago but developed ESRD again because of transplant failure. The patient has been on dialysis for the past year. The patient is now complaining of SOB and edema and is admitted for fluid overload and hemodialysis. Dialysis is performed multiple times during this stay.
A)E87.70, T86.12, N18.6, Z99.2, Y83.0, 5A1D60Z
B)N18.6, Z99.2, Z94.0, E87.70, 3E1M39Z
C)N18.6, T86.12, Z99.2, Y83.0, 5A1D60Z
D)E87.70, Z99.2, N18.6, Z94.0, 5A1D60Z
Q2) Can code Z94.0 and a T86.1-code be used together?
Q3) Occurs when bony healing is not achieved at the fracture site.
A)Malunion
B)Nonunion
C)Neuroma
D)Extravasation
E)Contracture
F)Necrosis
Q4) Complications affect only certain body systems.
A)True
B)False
Q5) What does DVT stand for?
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