Chapter 1
If a service is not documented in a patient's medical record (chart):
a. The provider can instruct the coder to write the documentation in the chart
b. It can still be billed to a private health plan, but not to a government health plan such as Medicare
c. It cannot be coded and cannot be billed
d. The medical coder can go back to the provider and ask for documentation after the fact
ICD-9-CM stands for which abbreviation?
a. Internal Catalog of Diseases, Ninth Revision, Clinical Modification
b. International Classification of Diseases, Ninth Revision, Clinical Modification
c. International Classification of Disorders, Ninth Revision, Clinical Modification
d. International Classification of Disorders, 9th ed., Complete Manual
Fourth and fifth digits provide additional specificity regarding the type of disease, the cause of the disease, or
a. The site of the disease
b. The complications of the disease
c. The length of the disease
d. The external source of illness or injury
That condition established after study to be chiefly responsible for occasioning the admission of the patient to the hospital for care.
a. Principal diagnosis
b. Definitive diagnosis
c. Secondary diagnosis
d. First listed diagnosis
The HIPAA mandated code set for outpatient diagnoses is:
a. HCPCS
b. ICD-9-CM Volume 3
c. CPT
d. ICD-9-CM Volumes 1 and 2
True or false - Under HIPAA, a patient must sign an authorization to release information required for payment of services.
These codes classify the causes of injuries, poisoning, and adverse events.
a. E codes
b. Subterms
c. Notes
d. V codes
When using the Alphabetic Index to code a condition documented as impending or threatened, and the terms impending or threatened are not listed as subterms, the coder should:
a. Code the existing underlying condition only?
b. Code the existing underlying condition as well
c. Code the condition as a late effect
d. Code the impending or threatened condition as if it did occur
This is usually the best place for the coder to begin the inpatient coding process because this document contains a recap of the entire hospitalization, summarizing the reason for admission and the tests, medications, and services provided.
a. Discharge summary
b. Face sheet
c. Disposition
d. Abnormal findings
The Patient's Reason for Visit is also known as:
a. The principal diagnosis
b. The secondary diagnosis
c. The patient's chief symptom or ill-defined condition
d. The patient's chief complaint or reason for the encounter
True or false - HIPAA stands for Health Insurance Protection and Authorization Act (HIPAA) of 1996.
This volume of the ICD-9-CM classifies procedures performed in the hospital inpatient setting.
a. Tabular List (Volume 1)
b. Alphabetic Index (Volume 2)
c. ICD-10-CM
d. Alphabetic Index and Tabular List of Procedures (Volume 3)
A term that indicates when two codes may be required to report a condition.
a. Mandatory multiple coding
b. Code to highest level of specificity
c. Code first underlying disease
d. See additional code
When two or more conditions meet the definition of principal diagnosis:
a. The codes should be sequenced n alphabetical order
b. The codes should be sequenced in the order the physician wrote them in the medical record
c. The codes may be sequenced in any order
d. Only one code should be listed
These are used to classify outpatient encounters for circumstances other than diseases and injuries.
a. CC codes
b. E codes
c. V codes
d. M codes
When a state law and the federal HIPAA regulations cover the same situation, which is followed?
a. Strictest law
b. Weakest law
c. Federal HIPAA regulations
d. State law
True or false - ICD-9-CM codes have between three and six digits.
When two separate conditions may be the cause of the symptom, the coder:
a. Codes only the symptom
b. Codes only the symptom and one diagnosis
c. Codes only the diagnoses
d. Codes both the symptom and the diagnoses
When a patients presents for an outpatient procedure or ambulatory surgery and the preoperative diagnosis and postoperative diagnosis are different, then:
a. The coder codes the postoperative diagnosis
b. The coder codes no diagnoses
c. The coder codes both diagnoses
d. The coder codes the preoperative diagnosis
Medical coders select correct diagnosis codes from which of the following sources:
a. ICD-9-CM
b. Designated Record Set (DRS)
c. HCPCS Level II
d. Current Procedural Terminology (CPT), Level I
This volume of the ICD-9-CM contains the diagnosis codes, supplementary classifications, and appendices and is the second volume that is consulted when coding.
a. ICD-10-CM
b. Alphabetic Index and Tabular List of Procedures (Volume 3)
c. Tabular List (Volume 1)
d. Alphabetic Index (Volume 2)
If a patient's condition is described as both acute and chronic, according to the ICD-9-CM Official Guidelines for Coding and Reporting:
a. Both conditions should be coded with the acute code first
b. Only the acute condition should be coded
c. Only the chronic condition should be coded
d. Both conditions should be coded with the chronic code first
Documentation supports two diagnoses using either/or or similar terminology, and both conditions are coded.
a. Diagnosis-related group (DRG)
b. Secondary diagnosis
c. Definitive diagnosis
d. Contrasting or comparative conditions
ICD-9-CM Volume 3 procedure codes are used:
a. Only for Medicare claims
b. In the outpatient setting only
c. Instead of HCPCS codes
d. In the inpatient setting only