Deck 1: Introduction to Diagnostic Coding

Question 1

Coding for _________ means that the code was selected based on what the insurance company will pay rather than what the documentation reflects.

A) coverage
B) payment
C) services
D) documentation

Answer 1

A

Question 2

A ____________ is a subjective sensation as expressed by the patient.

A) symptom
B) treatment
C) diagnosis
D) condition

Answer 2

A

Question 3

Hypertension is an example of a ____________.

A) symptom
B) diagnosis
C) procedure
D) complaint

Answer 3

B

Question 4

Outpatient coders cannot assign a diagnosis code for a diagnosis documented as:

A) likely.
B) possible.
C) questionable.
D) All of these

Question 5

You must code all ____________ or complications that are relevant to the current encounter.

A) admission diagnoses
B) conditions
C) factors
D) abuses

Question 6

A ________ code reports why the patient was seen by the physician.

A) condition
B) diagnosis
C) procedure
D) status

Question 7

Statistics show that for every $1 spent to pay for health care fraud and abuse investigations and prosecutions, the government actually brings in ___ in returned money.

A) $1
B) $2
C) $4
D) $6

Question 8

The official guidelines for ICD-10-CM are divided into ___ sections.

A) 2
B) 3
C) 4
D) 5

Question 9

_____________ is the practice of sending a claim for the second time to the same insurance company for the same procedure to the same patient for the same service date.

A) Unbundling
B) Double billing
C) Coding
D) Recording

Question 10

___________ created the Health Care Fraud and Abuse Control Program (HCFACP).

A) CMS
B) HIPAA
C) HHS
D) OIG

Question 11

A fever is an example of a(n) _________.

A) sign
B) objective
C) sensation
D) code

Question 12

The rules for ethical coding include the requirement for __________________.

A) obligation
B) business
C) s
D) claims

Question 13

_____________ is illegal because it reports a higher level of service or more severe condition than is true of the encounter with the patient.

A) Upcoding
B) Unbundling
C) Double billing
D) HIPAA

Question 14

The ________________ is a national organization for professional coding specialists.

A) Centers for Medicare and Medicaid Services
B) Office of the Inspector General
C) Department of Health and Human Services
D) American Health Information Management Association

Question 15

Asthma is an example of a(n) ____________.

A) diagnosis
B) procedure
C) indication
D) opinion

Question 16

A ___________ dictionary can help a coder find an alternate term that might be easier to find in the ICD-10-CM manual.

A) medical
B) Latin
C) spelling
D) coding

Question 17

ICD-10-CM contains codes for reporting ______________.

A) diagnoses
B) payers
C) systems
D) treatments

Question 18

Diagnosis codes can report a disease, a sign, or a(n) ________.

A) purpose
B) treatment
C) symptom
D) objective

Question 19

The ________________ can help a coder find the general or alternate name of a drug or an herbal remedy.

A) Physicians' Desk Reference
B) Merck Manual
C) Coding Clinic
D) medical dictionary

Question 20

The diagnosis code(s) ___________ the procedure provided to the patient during the encounter.

A) cause
B) justify
C) explain
D) document

Question 21

If a patient is diagnosed with chest pain due to an acute anterior wall myocardial infarction, what condition should be coded?

A) Chest pain
B) Myocardial infarction
C) Acute anterior wall myocardial infarction
D) Chest pain and acute anterior wall myocardial infarction

Question 22

Justifying a procedure code with a diagnosis code is known as:

A) medical necessity.
B) the National Correct Coding Initiative.
C) unbundling.
D) upcoding.

Question 23

Dizziness is an example of a:

A) symptom.
B) sign.
C) diagnosis.
D) procedure.

Question 24

Which position describes a patient lying on his or her back with a headrest bringing the head and torso up at a 45-degree angle?

A) Sim's
B) Fowler's
C) Knee-elbow
D) Proctologic

Question 25

A diagnosis is a physician's determination of all of the following except a patient's:

A) illness.
B) injury.
C) condition.
D) procedure.

Question 26

The physician documented Jacob's diagnosis as a chest cold. The coder assigned a code for bronchitis. This is an example of:

A) coding for coverage.
B) double billing.
C) following correct coding guidelines.
D) upcoding.

Question 27

A malignant neoplasm is a type of:

A) asthma.
B) bronchitis.
C) cancer.
D) dermatitis.

Question 28

The abbreviation RUQ stands for _____________.

A) right lower quadrant
B) left upper quadrant
C) right upper quadrant
D) left lower quadrant

Question 29

If there is unclear information in the documentation, the coder should:

A) code the diagnosis as though it existed.
B) not code the diagnosis.
C) query the physician.
D) give the chart to the coding supervisor to code.

Question 30

The abbreviation AP stands for _____________.

A) anteroposterior
B) posteroanterior
C) anterior oblique
D) posterior oblique

Question 31

The physician's notes state, "Chest congestion, possible pneumonia." The coder in the physician's office should:

A) code for pneumonia.
B) code for chest congestion.
C) query the physician.
D) All of these

Question 32

The seven steps of accurate coding include:

A) coding only documented conditions.
B) coding the problems told to you by the nurse.
C) coding only the chief complaint.
D) coding the patient's history.

Question 33

Which position describes a patient lying on her stomach face downward?

A) Prone
B) Supine
C) Sitting
D) Lithotomy

Question 34

Which of the following professional organizations has a code of ethics for coders to follow?

A) AAPC
B) AHIMA
C) Both AAPC and AHIMA
D) Neither AAPC nor AHIMA

Question 35

Where are the Official Guidelines for Coding and Reporting published?

A) In Appendix A of the ICD-10-CM manual
B) In the front of the ICD-10-CM manual
C) In Section III of the ICD-10-CM manual
D) In Section IV of the ICD-10-CM manual

Question 36

A professional coder should not:

A) code any condition that has not been documented.
B) send queries to the physician who cared for the patient.
C) read the physician's notes thoroughly.
D) code to the highest specificity.

Question 37

It is important that coders use credible resources, including:

A) medical dictionaries.
B) the Merck Manual.
C) Wikipedia.
D) medical dictionaries and the Merck Manual.

Question 38

Which of the following organ systems includes the brain and spinal cord?

A) Cardiovascular
B) Digestive
C) Nervous
D) Urinary

Question 39

What is the most important factor to consider when coding?

A) Accuracy
B) Productivity
C) Timeliness
D) All of these

Question 40

Unbundling is an example of ________.

A) payment
B) fraud
C) coverage
D) penalties

Question 41

It is important for coders to understand:

A) medical terminology.
B) anatomy and physiology.
C) the Physicians' Desk Reference.
D) medical terminology and anatomy and physiology.

Question 42

What does AAPC stand for?

A) American Academy of Professional Coders
B) American Association of Professional Coders
C) American Academy of Physician Coders
D) American Association of Physician Coders

Question 43

The directional term used to mean toward the bottom of the body is:

A) superior.
B) cephalad.
C) inferior.
D) caudal.

Question 44

Which of the following abbreviations is considered dangerous to use?

A) U
B) IU
C) Q.D.
D) All of these

Question 45

Who published the coding resource Coding Clinic?

A) AMA
B) AHA
C) AHIMA
D) AAPC

Question 46

A patient complains of dizziness. The physician states that she has hypertension. You will:

A) code for dizziness.
B) code for hypertension.
C) code for dizziness and hypertension.
D) query the physician.

Question 47

A coder who acts illegally may be:

A) fined monetarily.
B) retrained.
C) sentenced to jail.
D) fined monetarily and sentenced to jail.

Question 48

Jane complains of nausea. Dr. Mason orders her to go to the lab for a blood test to rule out pregnancy. You code:

A) nausea.
B) unspecified.
C) pregnancy.
D) nausea and pregnancy.

Question 49

AHIMA stands for:

A) American Health Information Management Association.
B) American Healthcare Insurance Monitoring Association.
C) American Health and Insurance Marketing Association.
D) American Healthcare Information and Medical Association.

Question 50

ICD-10-CM is an acronym for:

A) International Classification of Diseases, Tenth Revision, Clinical Modification.
B) International Classification of Diseases, Tenth Revision, Current Modification.
C) International Classification of Diagnoses, Tenth Revision, Clinical Modification.
D) International Classification of Diagnoses, Tenth Revision, Current Modification.