Which legislation requires you to follow the Official Guidelines for Coding and Reporting?
HIPAA
100
When the word “or” appears in the Tabular Index, it means
either of the diagnoses can be applicable
100
When reading coding guidelines, the following words are used interchangeably: visit, encounter, and
admission
100
A patient’s time under observation is considered
outpatient
100
The HCPCS has how many levels?
2
200
Who is legally accountable for establishing a patient's diagnosis?
physician
200
What kind of note indicates that you should go somewhere else if you are looking for a condition in the excludes list?
excludes notes
200
V codes are listed as the first diagnosis to show the reason for a visit when, in an outpatient setting, the physician
is unsure of the diagnosis
200
What is the term for when a physician has determined a final diagnosis for a patient’s condition?
definitive diagnosis
200
The first level of the HCPCS is the same as
CPT-4 codes
300
phrase other or other specified in the Tabular List means that the physician
specified the patient's condition in the documentation, but there is no ICD-9-CM code for it
300
What should you trust for the final wording of the code?
the Alphabetic Index
300
If a patient comes to the physician with a suspected urinary tract infection and ends up having a mole removed, what is the first- listed diagnosis?
the symptoms of the suspected urinary tract infection
300
If a diagnosis is coded to its highest specificity, the code will have
3–5 digits
300
What letters are used in Level I of the HCPSC (CPT-4)?
T and F
400
What is the risk of not coding to the highest specificity?
lower reimbursement
400
What term may be included in the code title instead of the abbreviation NOS?
unspecified
400
The term that refers to a condition that makes a treatment or procedure inadvisable is
contraindication
400
The first step in finding the main reason for an encounter is to
read the documentation for this encounter
400
What codes are specific to the setting of the procedure?
Evaluation and management codes
500
What diagnosis is defined as the pancreas not producing enough insulin and too much sugar in the patient's blood?
diabetes mellitus
500
Arthritis is an example of a(n)
late effect
500
What is the method of performing surgery in which a physician inserts a thin, rigid tube through a small incision (about 1 cm) in the patient's abdomen?
laparoscopy
500
If a disease or condition affects the treatment of the first-listed diagnosis, it is coded in addition to the first diagnosis. This second diagnosis is referred to as a(n)
coexisting diagnosis
500
If a code(s) is separated by a comma, then a code range is