Question 1

The __________, if available, is the first step in the process of record review for code selection.

Accepted Answer

The answer of The __________, if available, is the first...

Question 2

Which of the following is a basic step in coding?

Accepted Answer

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. 
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.

Question 3

A coder must always remember that, after a term is located in the Alphabetic Index, the code must be verified in the Tabular List.

Accepted Answer

A) True 
 B)False

Question 4

The main term in "aplastic anemia" is ____.

Accepted Answer

A) anemia 
B) aplasia 
C) aplastic 
D) none of the above 
A) anemia 
B) aplasia 
C) aplastic 
D) none of the above

Question 5

Match each definition to one of the following items.
-When a patient displays a symptom that could represent a variety of diagnoses

Accepted Answer

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 
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

Question 6

Exceptions to the general rule that main terms usually identify disease conditions are Z codes.

Accepted Answer

A) True 
 B)False

Question 7

What is the main term in "esophageal reflux"?

Accepted Answer

The answer of What is the main term in "esophageal...

Question 8

What is the subterm in "esophageal reflux"?

Accepted Answer

The answer of What is the subterm in "esophageal reflux"?...

Question 9

Match each definition to one of the following items.
-Synopsis of the events of a patient's hospital encounter

Accepted Answer

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 
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

Question 10

In the discharge summary, a physician lists the __________ that were evaluated and treated and any procedures that were performed.

Accepted Answer

The answer of In the discharge summary, a physician lists...

Question 11

What is the main term in "infantile eczema"?

Accepted Answer

The answer of What is the main term in "infantile...

Question 12

What is the subterm in "infantile eczema"?

Accepted Answer

The answer of What is the subterm in "infantile eczema"?...

Question 13

The admitting diagnosis is usually a sign or a symptom.

Accepted Answer

A) True 
 B)False

Question 14

When evaluating an ER record, a coder should look for the ____.

Accepted Answer

A) diagnosis 
B) chief complaint 
C) probable diagnosis 
D) differential diagnosis 
A) diagnosis 
B) chief complaint 
C) probable diagnosis 
D) differential diagnosis

Question 15

What is the subterm in "rheumatoid arthritis"?

Accepted Answer

The answer of What is the subterm in "rheumatoid arthritis"?...

Exam 4: Basic Steps of Coding

The __________, if available, is the first step in the process of record review for code selection.

Which of the following is a basic step in coding?

A coder must always remember that, after a term is located in the Alphabetic Index, the code must be verified in the Tabular List.

The main term in "aplastic anemia" is ____.

Match each definition to one of the following items. -When a patient displays a symptom that could represent a variety of diagnoses

Exceptions to the general rule that main terms usually identify disease conditions are Z codes.

What is the main term in "esophageal reflux"?

What is the subterm in "esophageal reflux"?

Match each definition to one of the following items. -Synopsis of the events of a patient's hospital encounter

In the discharge summary, a physician lists the __________ that were evaluated and treated and any procedures that were performed.

What is the main term in "infantile eczema"?

What is the subterm in "infantile eczema"?

The admitting diagnosis is usually a sign or a symptom.

When evaluating an ER record, a coder should look for the ____.

What is the subterm in "rheumatoid arthritis"?

The Rationale for and History of Coding

The Health Record As the Foundation of Coding

ICD-10-Cm Format and Conventions

General Coding Guidelines for Diagnosis

Introduction to Icd-10-PCS

General Coding Guidelines for Other Medical- and Surgical-Related Procedures and Ancillary Procedures

Coding Medical and Surgical Procedures

Symptoms, Signs, and Abnormal Clinical and Laboratory Findings Not Elsewhere Classified, and Z Codes

Certain Infectious and Parasitic Diseases

Neoplasms

Diseases of the Blood and Blood-Forming Organs and Certain Disorders Involving the Immune Mechanism

Endocrine, Nutritional, and Metabolic Diseases

Mental, Behavioral, and Neurodevelopmental Disorders

Diseases of the Nervous System, Diseases of the Eye and Adnexa, and Diseases of the Ear and Mastoid Process

Diseases of the Circulatory System

Diseases of the Respiratory System

Diseases of the Digestive System

Diseases of the Skin and Subcutaneous System

Diseases of the Musculoskeletal System and Connective Tissue

Diseases of the Genitourinary System

Pregnancy, Childbirth, and the Puerperium

Certain Conditions Originating in the Perinatal Period and Congenital Malformations, Deformations, and Chromosomal Abnormalities

Injuries and Certain Other Consequences of External Cases and External Causes of Morbidity

Burns, Adverse Effects, and Poisonings

Complications of Surgical and Medical Care

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