Deck 12: Basics of Diagnostic Coding

Question 1

Medical assistants have the trust of the physician and practice that employs them. A medical assistant must

A) adhere to ethical standards concerning assigning and reporting codes clearly.
B) be responsible and knowledgeable to ensure that no fraud takes place in coding.
C) be responsible and knowledgeable to ensure that no fraud takes place in claim submission.
D) All of the above

Answer 1

All of the above

Question 2

The abbreviation that is the equivalent of "unspecified" is __________.

Answer 2

NOS

Question 3

Which of the following instructions in the Alphabetic Index indicates that another main term may reference additional useful index entries?

A) See
B) See also
C) See category
D) And
E) Due to

Answer 3

See also

Question 4

Which of the following terms defines a malignant neoplasm site as the absence of invasion of surrounding tissues?

A) Primary
B) Secondary
C) In situ
D) Benign

Question 5

Which of the following ICD-10-CM sections includes guidelines for reporting additional diagnoses in non-outpatient settings?

A) Section I
B) Section II
C) Section III
D) Section IV
E) Section V

Question 6

Burns are coded by

A) site and degree.
B) the body surface involved.
C) Both A and B
D) None of the above

Question 7

The code HIV indicates which of the following?

A) The HIV virus is present
B) The manifestation of and/or symptoms that occur as a result of HIV infection
C) Probable case of HIV
D) Suspected case of HIV

Question 8

When a Code First Note is present and the patient has an underlying condition, the underlying condition should be sequenced first. Wherever such a combination exists, a Use Additional Code Note is found with the etiology code, and a Code First Note is found with the manifestation code.

A) Both statements are true.
B) Both statements are false.
C) The first statement is true; the second is false.
D) The first statement is false; the second is true.

Question 9

Which of the following terms applies to the period from the last month of pregnancy to 5 months after giving birth?

A) Antepartum
B) Childbirth
C) Postpartum
D) Peripartum

Question 10

Babies are considered newborn or perinatal for the first ______ days.

A) 30
B) 29
C) 28
D) 27

Question 11

The signs and symptoms of a disease are its __________.

Question 12

A code from category Z37 should be included on

A) every maternal record when a delivery has occurred.
B) subsequent records.
C) newborn records.
D) Both A and B

Question 13

All conditions that occur during or following medical care or surgery are classified as complications. There must be a cause-and-effect relationship between the care provided and the condition, and an indication in the documentation that it is a complication.

A) Both statements are true.
B) Both statements are false.
C) The first statement is true; the second is false.
D) The first statement is false; the second is true.

Question 14

How are subterms treated in the alphabetic index to diseases and injury?

A) Bold type
B) Enclosed in parentheses
C) Italicized
D) Indented two spaces under the level of the preceding line

Question 15

Which volume(s) of ICD-9-CM is/are used for diagnostic coding?

A) Volume 1
B) Volume 2
C) Volume 3
D) Both A and B

Question 16

Which of the following is the second most common medical document from which diagnostic statements can be extracted?

A) Encounter form
B) Treatment notes
C) Discharge summary
D) Radiology, laboratory, or pathology report

Question 17

Which of the following codes will be used for a patient with a history of myocardial infarction with no symptoms but diagnosed by means of an electrocardiogram?

A) Category I21
B) Code I25.2
C) Code I21.3
D) None of the above

Question 18

Which of the following letters in the ICD-10-CM is reserved by the World Health Organization to assign new diseases with uncertain etiology?

A) U
B) X
C) Y
D) Z

Question 19

When coding for drug toxicity, which of the following refers to a condition when a patient takes less of a medication than is prescribed by his or her provider or by the manufacturer's instructions?

A) Adverse effect
B) Poisoning
C) Underdosing
D) Toxic effect

Question 20

The cause of a disorder is its __________.

Question 21

Carcinoma __________ is defined as the absence of invasion of surrounding tissues.

Question 22

The __________ table describes malignancies.

Question 23

Main terms appear in bold type.

Question 24

______________ are notes included in the Tabular Index to provide additional guidance for selected diagnosis codes.

Question 25

The "code first" notation can usually be ignored.

Question 26

The codes for pernicious anemia and a vitamin B₁₂ deficiency are the same.

Question 27

A neoplasm or new growth is coded by the site or location of the neoplasm and its behavior.

Question 28

Burns are coded to the site by __________.

Question 29

At times, the medical assistant must code a(n) __________ if the physician is not yet sure of the diagnosis.

Question 30

The medical assistant should never code a patient as having __________ unless it is clearly documented as confirmed in the medical record.

Question 31

Etiology refers to the underlying cause or origin of a disease.

Question 32

The coder should always refer to the Tabular Index first.