Medical Coding and Classification Systems
Review Questions
Course Introduction
This course provides a comprehensive introduction to medical coding and classification systems used in healthcare settings. Students will learn to accurately interpret clinical documentation and assign appropriate codes using standardized coding systems such as ICD-10-CM/PCS, CPT, and HCPCS Level II. Emphasis is placed on understanding coding guidelines, conventions, and ethical considerations, as well as the role coding plays in healthcare reimbursement, data analysis, and regulatory compliance. Through practical exercises and real-world case studies, students will develop essential skills required for effective coding, billing processes, and preparation for professional certification exams in medical coding.
Recommended Textbook
ICD 10 CM PCS Coding Theory and Practice 2016 Edition 1st Edition by Karla R. Lovaasen
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27 Chapters
1674 Verified Questions
1674 Flashcards
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Chapter 1: The Rationale for and History of Coding
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46 Verified Questions
46 Flashcards
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Sample Questions
Q1) Personal health information can be shared with ____.
A)those who have a need to know
B)people requesting information on the phone
C)your neighbors
D)all of the above
Answer: A
Q2) In a closed system like the ICD-10-CM system,a disease,condition,or procedure can be classified only in ____ location(s).
A)one
B)two
C)three
D)four
Answer: A
Q3) ICD-10-CM can be updated _________ times each year.
Answer: 2 two
Q4) Without the __________ system,the comparison of data would be impossible.
Answer: classification
Q5) WHO stands for __________.
Answer: World Health Organization
Page 3
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Chapter 2: The Health Record As the Foundation of Coding
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39 Flashcards
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Sample Questions
Q1) Subjective
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: B
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4
Chapter 3: ICD-10-Cm Format and Conventions
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Sample Questions
Q1) What are the two tables found in the Alphabetic Index in ICD-10-CM?
Answer: Neoplasm Table and the Table of Drugs and Chemicals
Q2) 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
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) "____" is used in the Alphabetic Index to provide guidance when two conditions are related or have a causal relationship.
A)With
B)See condition
C)See category
D)And
Answer: A
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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) Modifiers of the main term that have an effect on the appropriate code choice
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) A differential diagnosis is when a patient presents with a symptom that is usually related to only one possible diagnosis.
A)True
B)False
Q4) What is the main term in "rheumatoid arthritis"?
Q5) What is the subterm in "rheumatoid arthritis"?
Q6) The __________,if available,is the first step in the process of record review for code selection.
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Chapter 5: General Coding Guidelines for Diagnosis
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Sample Questions
Q1) When you assign separate codes that are used to identify acute and chronic conditions,the acute code is sequenced first.
A)True
B)False
Q2) A patient comes to the hospital with unstable angina.Serial cardiac enzymes and EKGs are performed,and anterolateral myocardial infarction is confirmed.The patient develops congestive heart failure on day 2 of the hospital stay.What is the principal diagnosis?
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) What are the diagnosis code(s) for acute and chronic pancreatitis?
Q5) What is the diagnosis code(s) for thoracolumbar scoliosis (neuromuscular) due to past history of poliomyelitis?
Q6) Principal diagnosis is defined in the Uniform Hospital Discharge Data Set (UHDDS) as that condition established after study to be chiefly responsible for occasioning the admission of the patient to the hospital for care.
A)True B)False
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Chapter 6: General Coding Guidelines for Medical and Surgical Procedures
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173 Flashcards
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Sample Questions
Q1) Alphabetic Index entry for fragmentation left ureteral stone
Q2) Cutting into a body part without draining fluids and/or gases from the body part in order to separate or transect a body part is called ____.
A)reattachment
B)release
C)transfer
D)division
Q3) Which of the following is a characteristic of ICD-10-PCS?
A)Codes are alphanumeric
B)They are similar to ICD-10-CM diagnosis codes
C)Number of codes is limited
D)Codes are three to four digits
Q4) The approach for removal of a skin lesion is external.
A)True
B)False
Q5) Therapeutic paracentesis of peritoneal cavity,percutaneous
Q6) Alphabetic Index entry for reattachment right hand
Q7) Laparoscopic lysis of adhesions,small bowel
Q8) Percutaneous aspiration of left perirenal abscess Page 8
Q9) ____________________ stands for intensive care unit.
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Page 9
Chapter 7: General Coding Guidelines for Other Medical-
and Surgical-Related Procedures and Ancillary Procedures
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107 Verified Questions
107 Flashcards
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Sample Questions
Q1) Immobilization is limiting or preventing motion of a body region.
A)True
B)False
Q2) Therapeutic massage is coded in the other procedures section.
A)True
B)False
Q3) The first character value for substance abuse treatment is H.
A)True
B)False
Q4) EEG monitoring,external
Q5) Low cervical cesarean section would be identified by the fifth character,approach.
A)True
B)False
Q6) Mechanical respiratory ventilation longer than 96 hours
Q7) Physical therapy treatment to increase ROM shoulder
Q8) The first character value for a physical rehabilitation or diagnostic audiology procedure is I.
A)True
B)False Page 10
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Chapter 8: Symptoms,
Signs, and
Abnormal
Clinical and Laboratory Findings Not Elsewhere Classified, and Z Codes
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Sample Questions
Q1) Screening for sickle cell disorder: __________
Q2) 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
Q3) Screening for osteoporosis: __________
Q4) ICD-10-CM provides codes to deal with encounters for circumstances other than a disease or injury.
A)True
B)False
Q5) Camp physical: __________
Q6) Encounter for admission examination for prisoner: __________
Q7) Urethral discharge: __________
12
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Chapter 9: Certain Infectious and Parasitic Diseases
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63 Flashcards
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Sample Questions
Q1) How many stages of syphilis are there?
A)One
B)Two
C)Three
D)Four
Q2) Tuberculosis usually occurs in populations with weaker immune systems.This would include all of the following EXCEPT ____.
A)people with HIV
B)substance abusers
C)teenagers
D)young children
Q3) TB stands for ____________________.
Q4) Assign the code for chicken pox.
Q5) ____________________,or shingles,is a disease caused by the same virus that causes chickenpox.
Q6) Clostridium difficile is often seen in ____ hospitalized patients.
A)infant
B)children
C)teenaged
D)elderly
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Chapter 10: Neoplasms
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Sample Questions
Q1) 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
Q2) 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
Q3) Patient was admitted for prophylactic removal of ovaries due to genetic susceptibility and positive family history of ovarian cancer with laparoscopic removal of both ovaries.
A)Z40.02,Z80.41,Z15.02,0UT04ZZ,0UT14ZZ
B)Z15.02,Z80.41,Z40.02,0UT20ZZ
C)Z40.09,Z80.41,Z15.02,0UT24ZZ
D)Z40.02,Z80.41,Z15.02,0UT24ZZ
Q4) Lymphangioendothelioma: __________
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Chapter 11: Diseases of the Blood and Blood-Forming
Organs and Certain Disorders Involving the Immune
Mechanism
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Sample Questions
Q1) Patient was admitted to the hospital with usual pain symptoms for sickle cell/Hb-SS disease.Patient did not fill the pain medication prescription,and recent cold weather has brought on a vaso-occlusive crisis.Chest X-ray was performed and revealed evidence of acute chest syndrome.Patient has had right hip replacement for avascular necrosis and is scheduled to have the left hip replaced next month because of avascular necrosis,which is due to Patient's sickle cell disease.Final Diagnosis: Sickle cell crisis with acute chest syndrome.Status post hip replacement.
A)D57.00,Z96.642,M90.559
B)D57.01,Z96.642,M90.551
C)D57.01,Z96.641,M90.552,Z91.14
D)D57.00,Z96.641,M90.552,Z91.11
Q2) A patient is admitted with neutropenic fever.Patient has been receiving chemotherapy for acute myeloid leukemia.No source of infection is identified,and it is thought that Patient's neutropenia is due to chemotherapy.Patient is discharged.
A)T45.1x5A,D70.2,R50.81,C92.02
B)R50.81,D70.1,T45.1x5A,C92.01
C)T45.1x1A,D70.1,C92.00
D)D70.1,R50.81,T45.1x5A,C92.00
Page 15
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Chapter 12: Endocrine, Nutritional, and Metabolic Diseases
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Sample Questions
Q1) With regard to reimbursement,what does CC stand for?
Q2) Myxedema is a skin or tissue disorder usually resulting from severe,prolonged hypothyroidism.
A)True
B)False
Q3) TLS stands for ____________________.
Q4) Vitamin D deficiency: __________
Q5) 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
Q6) Hypoglycemia: __________
Page 16
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Chapter 13: Mental, Behavioral, and Neuro developmental Disorders
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Sample Questions
Q1) Drug withdrawal treatment depends on the drug from which a person is having withdrawal.
A)True
B)False
Q2) Organic psychosis occurs because of deterioration in the brain and is usually progressive and irreversible.
A)True
B)False
Q3) Asexual transsexualism: __________
Q4) 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
Q5) A patient has a history of PTSD and arrives at the ER with extreme anxiety.The patient has been noncompliant with medications and recently has been under a great deal of stress and indicates suicidal ideation.The patient is admitted for monitoring and reinstitution of medications for exacerbation of chronic PTSD.
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Eye and Adnexa,and Diseases of the Ear and Mastoid
Process
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Sample Questions
Q1) The spinal cord is located in the ____________________ foramen.
Q2) An infection or inflammation of the meninges
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) What are the two main divisions of the nervous system?
Q4) What drug could be given to treat epilepsy?
A)Dilantin
B)Cognex
C)Aricept
D)Sinemet
Q5) Meningitis due to Klebsiella: __________ Page 18
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Chapter 15: Diseases of the Circulatory System
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Sample Questions
Q1) Prinzmetal angina: __________
Q2) Disorder of the muscle of the heart chambers that impedes the functioning 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) A patient is admitted with three-vessel coronary artery disease for coronary artery bypass.The patient has had a previous stroke and is receiving Coumadin.The patient has a history of aortic porcine valve replacement and also has hyperlipidemia and a strong family history of sudden cardiac death.The patient is taken to the OR for an open three-vessel aorta to coronary artery using greater saphenous vein.The left greater saphenous vein was harvested via percutaneous approach.Cardiopulmonary bypass is performed during the surgery.
Q4) The normal heart rate of a healthy adult is between _____ and _____ beats per minute.
Page 20
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Chapter 16: Diseases of the Respiratory System
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Sample Questions
Q1) 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
Q2) History of tobacco use
A)Z82.5
B)Z83.6
C)Z87.891
D)Z85.22
E)Z48.24
F)Z77.090
G)Z93.0
Q3) In ICD-10-CM,if a respiratory condition occurs in more than one site and is not specifically indexed,each site should be coded separately.
A)True
B)False
Q4) The abbreviation ABG stands for ____________________.
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Chapter 17: Diseases of the Digestive System
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Sample Questions
Q1) Name one purpose of the small intestine.
Q2) Patient is admitted with hematochezia.A colonoscopy is performed and diverticulitis was found to be the source of the bleeding.
A)K92.1,K57.33,0DJD8ZZ
B)K57.33,0DJD8ZZ
C)K57.32,K92.1,0DJD7ZZ
D)K92.1,K57.32,0DJD7ZZ
Q3) Postgastrectomy diarrhea: __________
Q4) What are the three parts of the small intestine?
Q5) A patient presents with melena,weakness,and fatigue.A colonoscopy with biopsy of the rectum and colon is performed and reveals multiple diverticula and internal hemorrhoids.No source of bleeding is identified.Discharge Diagnosis: GI bleed;chronic blood loss anemia.
A)D50.0,K92.2,K57.91,K64.8,0DBE8ZX
B)K92.1,D50.0,K57.30,K64.8,0DBE8ZX,0DBP8ZX
C)K92.2,D62,K57.30,K64.9,0DBE8ZX,0DBP8ZX
D)K57.91,K92.1,D50.0,K64.9,0DBE8ZX,0DBP8ZX
Q6) The mouth is where digestion begins.
A)True
B)False
Page 22
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Chapter 18: Diseases of the Skin and Subcutaneous Tissue
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Sample Questions
Q1) Exfoliative dermatitis: __________
Q2) Dermatitis from gold ring: __________
Q3) A(n) ____ is a skin graft from one person to another.
A)allograft
B)autograft
C)xenograft
D)mesnograft
Q4) 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
Q5) The assignment of the code for unstageable pressure ulcer should be based on clinical documentation.
A)True
B)False
Q6) What is an abscess of the skin?
Q7) What usually causes hives?
Page 23
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Chapter 19: Diseases of the Musculoskeletal System and Connective Tissue
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Sample Questions
Q1) Organ or tissue replaced by other means-right hip
A)Z87.39
B)Z82.61
C)Z82.69
D)Z96.641
E)Z89.512
F)Z13.828
G)Z13.820
Q2) ____ is/are the front of the body or organ.
A)Anterior
B)Dorsal
C)Proximal
D)Ventral
E)Anterior and ventral
Q3) 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
Page 24
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Chapter 20: Diseases of the Genitourinary System
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Q1) Hydronephrosis is the abnormal ____________________ of the renal pelvis caused by pressure from urine that cannot flow past an obstruction in the urinary tract.
Q2) Mittelschmerz: __________
Q3) Vesicoperineal fistula: __________
Q4) Patient is seen for CKD stage IV.The patient's kidney transplant has failed and may have to go receive dialysis in the near future.
A)T86.12,N18.4,Y83.0
B)N18.4,T86.12,Y83.0
C)N18.4,Z94.0
D)N18.6,T86.12
Q5) What type of dialysis uses the peritoneal membrane to filter out wastes and excess fluid?
A)HD
B)CAPD
C)CCPD
D)COPD
Q6) In ICD-10-CM,there is a code to identify postprocedural renal failure.
A)True
B)False
Page 25
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Chapter 21: Pregnancy, Childbirth, and the Puerperium
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Q1) A woman pregnant at 43 weeks is still considered to be a term pregnancy.
A)True
B)False
Q2) Mother with mastitis due to nursing.Delivered 8 days ago: __________
Q3) What drug could be given to inhibit labor?
A)Cervidil
B)Terbutaline
C)Pitocin
D)Demerol
Q4) The patient is admitted in labor at term.After lab work is completed,it is noted that the patient has a UTI and appears to be preeclamptic.The patient goes on to vaginally deliver a healthy baby boy.
A)O23.42,O14.93,Z37.0,Z3A.38,10E0XZZ
B)O23.23,O14.93,Z3A.38,Z38.00,10E0XZZ
C)O23.43,O14.93,Z3A.38,Z37.0,10E0XZZ
D)O23.33,O14.03,Z3A.38,Z38.00,10E0XZZ
Q5) Patient comes to the hospital at 39 weeks with convulsions;baby is taken emergently by low cervical C-section: __________
Q6) What is tested for in a female's urine sample to confirm that she is pregnant?
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Chapter 22: Certain Conditions Originating in the Perinatal
Period and Congenital Malformations, deformations, and
Chromosomal Abnormalities
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Q1) Which of the following makes a condition clinically significant?
A)The condition requires a clinical evaluation
B)The condition requires therapeutic treatment
C)The condition requires an extended hospital stay
D)All of the above are correct
Q2) What is the most common treatment for infants with moderate jaundice?
Q3) Spina bifida is a curable congenital anomaly because there is a way to repair the damaged nerve tissue.
A)True
B)False
Q4) When locating infections of the newborn,it is best to look under the main term for the infection and then to look for a subterm of newborn,fetal,or congenital.
A)True
B)False
Q5) Which of the following is NOT a congenital condition?
A)Marfan syndrome
B)Down syndrome
C)Bronchopulmonary dysplasia
D)Klinefelter's syndrome
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Chapter 23: Injuries and Certain Other Consequences of
External Cases and External Causes of Morbidity
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Q1) An injury to the brain that results from a significant blow to the head is called a(n)
Q2) The body part is subjected to a high degree of force or pressure,usually after being squeezed between two heavy or immobile objects
A)Crush injury
B)Fissured fracture
C)Comminuted fracture
D)Greenstick fracture
E)External skeletal fixation
F)Contusion
Q3) A ____ is a stretch and/or tear of a ligament.
A)dislocation
B)subluxation
C)sprain
D)strain
Q4) Injury to spleen with massive parenchymal disruption (major laceration) and a total splenectomy (open) was performed,initial encounter: __________
Q5) When air or gas bubbles get into the bloodstream,what is one thing that can happen?
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Chapter 24: Burns, adverse Effects, and Poisonings
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Q1) 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,that 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
Q2) Blisters have formed,and there is epidermal loss
A)First-degree
B)Second-degree
C)Third-degree
D)Fourth-degree
Q3) Which of the following can be used to treat burns?
A)Antibiotics
B)Anti-inflammatories
C)Corticosteroids
D)All of the above
Q4) What are the four major types of abuse?
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Chapter 25: Complications of Surgical and Medical Care
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Q1) Patient with a history of a kidney transplant comes to the ER with gastroenteritis.His history is positive for CKD,stage 2,and hypertension.
A)T86.10,I12.9,Z94.0
B)K52.9,I10,5N18.2,Z94.0
C)T86.10,I10,N18.2
D)K52.9,I12.9,N18.2,Z94.0
Q2) Patient was admitted for 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) Iatrogenic is a term used to signify that a condition is a result of treatment.
A)True
B)False
Q4) What are some examples of procedures resulting in complications that occur during medical care and not during surgery?
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Chapter 26: Reimbursement Methodologies
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43 Verified Questions
43 Flashcards
Source URL: https://quizplus.com/quiz/42625
Sample Questions
Q1) Medicare is responsible for more than ___% of patients.
Q2) How do you calculate case-mix index?
Q3) This refers to a preexisting condition (i.e.,it is present on admission)
A)Complication
B)Comorbidity
C)Quality Improvement Organization (QIO)
D)PEPPER-Program for Evaluating Payment Patterns Electronic Report
E)Postacute Transfer Policy
Q4) Medicare was established in what year?
A)1995
B)1935
C)1965
D)1945
Q5) The Quality Improvement Organizations function under ___-year contracts called SOW.
A)1
B)3
C)6
D)9
Q6) MS-DRG stands for __________.
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Chapter 27: Out patient Coding
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Source URL: https://quizplus.com/quiz/42626
Sample Questions
Q1) What are APCs and what do they do?
Q2) A patient is admitted to ambulatory surgery with a diagnosis of right senile cataract.A phacoemulsification with insertion of an intraocular lens is performed:
Q3) CPT codes are in ____-digit numeric codes.
A)Two
B)Three
C)Four
D)Five
E)Six
Q4) When using ICD-10-CM/PCS,outpatient coders will be using ICD-10-PCS instead of CPT.
A)True
B)False
Q5) What are ancillary service visits?
Q6) To prevent coding errors,a coder should never begin searching initially in the ____________________ when looking for the correct code.
Q7) When a patient is admitted for observation for a medical condition,assign a code for the medical condition as the ____________________.
Page 33
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