Deck 2: Foundations of ICD-10-CM

Question 1

The ICD-10-CM manual provides the ___________ for the patient's service or procedure.

A) Why
B) Where
C) When
D) How

Answer 1

Why

Question 2

There are currently no guidelines for these chapters:

A) Diseases of the Blood and Blood-forming Organs and Certain Disorders Involving the Immune Mechanism, Diseases of the Ear and Mastoid Process, and Diseases of the Digestive System
B) Diseases of the Respiratory System, Mental and Behavioral Disorders, and Diseases of the Blood and Blood-Forming Organs and Certain Disorders Involving the Immune Mechanism
C) Diseases of the Circulatory System, Mental and Behavioral Disorders, and Diseases of the Nervous System
D) Diseases of the Respiratory System, and Diseases of the Ear and Mastoid Process

Answer 2

Diseases of the Blood and Blood-forming Organs and Certain Disorders Involving the Immune Mechanism, Diseases of the Ear and Mastoid Process, and Diseases of the Digestive System

Question 3

In ICD-10-CM, the note indicating that the condition being coded is located elsewhere in the manual and should never be coded with the code under which it is located is the:

A) Excludes B
B) Excludes 2
C) Excludes 1
D) Excludes A

Answer 3

Excludes 1

Question 4

Excludes 1 and Excludes 2 notes can be found in all of the following locations in the ICD-10-CM manual except:

A) Directly below the code
B) Beginning of the index entry
C) Beginning of a section
D) Beginning of a chapter

Question 5

A facility coder notes that a provider has documented a salpingo-oophorectomy was performed on a male patient. The coder relied on her knowledge of __________ to determine this is an impossible coding scenario.

A) facility capabilities
B) third-party payer guidelines
C) medical terminology
D) provider's specialty

Question 6

An unspecified code would be assigned to a code known as a ___________ code.

A) Not found elsewhere
B) Not elsewhere classified
C) Not otherwise specified
D) Not elsewhere specified

Question 7

Impending or threatened conditions are:

A) Conditions produced after the initial injury or condition has healed
B) Codes located directly behind the main term and used only when the documentation has no additional detail on the condition or disease
C) Codes that are unspecified or are most often used with a condition
D) Specific diagnostic conditions whose codes are used only when the condition was averted due to medical intervention

Question 8

In ICD-10-CM, the following notation indicates that separate associated complication or comorbidity is not present:

A) without
B) not including
C) see also
D) not otherwise specified

Question 9

A coder identifies _______ when he/she determines the answer to the question "What did the patient suffer from?"

A) The default code
B) The extender
C) The sequel
D) The main term

Question 10

The ability of a coder to accurately and efficiently assign proper diagnosis codes within compliance guidelines relies on his/her knowledge of all of the following except:

A) pathophysiology
B) pharmacology
C) medical terminology
D) basic coding rules and guidelines

Question 11

A sign is a(n):

A) A summary of a patient's concurrent conditions
B) The type of procedure performed
C) Objective condition that can be measured and recorded
D) Subjective condition that is relayed to the provider by the patient

Question 12

How many chapters does the ICD-10-CM manual contain?

A) 20
B) 22
C) 21
D) 19

Question 13

What is an abbreviation that means "not elsewhere classified?"

A) NOWS
B) NEWC
C) NEC
D) NOS

Question 14

Per ICD-10-CM guidelines, the use of the word "and" is interpreted to mean:

A) and/also
B) and/along with
C) and/with
D) and/or

Question 15

Select the true statement below regarding the CPC coding exam

A) The CPC exam is based on ICD-10-PCS
B) The CPC exam is based on inpatient/facility DRG coding
C) The CPC exam is based on ICD-10-CM, CPT, and HCPCS
D) The CPC exam is a 4 hour 40 minute tests

Question 16

An acute condition is one that:

A) has a sudden onset
B) has a slow onset
C) is of long duration
D) can last a lifetime

Question 17

A condition with slow onset and of long duration, even the lifetime of the patient, is known as a(n) ___________ condition.

A) chronic
B) genetic
C) bacterial
D) acute

Question 18

The statement in the ICD-10-CM Official Guidelines "that condition established after study to be chiefly responsible for the admission of the patient to the hospital for care" is a definition of a:

A) principal diagnosis
B) first-listed diagnosis
C) precedence diagnosis
D) supplemental diagnosis

Question 19

What does the index of the ICD-10-CM manual contain?

A) The nomenclature of each code
B) An alphabetic listing of main terms identifying conditions
C) The full description of each code
D) An alphabetic listing of main terms identifying procedures

Question 20

Elevated blood pressure is an example of a:

A) Virus
B) Symptom
C) Sign
D) Syndrome

Question 21

Square brackets identify mandatory sequencing of etiology-manifestation coding in the:

A) Procedural Coding System
B) Alphabetic Index
C) Tabular List
D) Clinical Modification

Question 22

The diagnosis code selected from the ICD-10-CM manual provides the support for the patient's:

A) return visit
B) copay
C) fee schedule
D) service

Question 23

A condition with sudden onset, usually without warning, and of brief duration is a(n) ___________ condition.

A) bacterial
B) genetic
C) chronic
D) acute

Question 24

The Tabular List of the ICD-10-CM manual is divided into chapters based on:

A) Body systems or conditions
B) Conditions listed alphabetically
C) Injuries, signs, and symptoms
D) Body systems

Question 25

The following notation implies sequencing of the codes when reported:

A) See also
B) Code also
C) Use additional code
D) See

Question 26

What is another name for the full description of an ICD-10-CM code?

A) Identifier
B) Nomenclature
C) Indentation
D) Definition

Question 27

The patient's diagnostic story is told by:

A) Using the ICD-10-CM manual as a translation dictionary
B) Providing supporting provider documentation with each CMS 1500 claim form
C) ICD-10-PCS
D) The Medical Assistant conveying a patient's vital signs to the provider

Question 28

Select the true statement regarding guidelines and conventions:

A) Guidelines or conventions listed at the chapter level take precedence over those listed at the section level.
B) Guidelines or conventions listed at the section level in the Tabular List take precedence over those at the code level.
C) The closer the guideline or convention is to Section IV, I in the manual, the higher it is in the hierarchy of guidelines
D) The closer the guideline or convention is to the code in the Tabular List, the higher it is in the hierarchy of guidelines

Question 29

When the acute and chronic forms of a condition are present:

A) Both the acute and chronic forms of the condition should be coded if separate subentries exist in the Alphabetic Index
B) The chronic form of the condition only should be coded
C) A combination code must be used
D) The acute form of the condition only should be coded

Question 30

The ICD-10-CM code A04.8 "Other specified bacterial intestinal infections" would be appropriate to assign when the cause of a patient's enteritis is not specifically described in a more specific ICD-10-CM code. This is an example of a:

A) Not elsewhere classified code
B) Not otherwise specified code
C) See code
D) See also code

Question 31

The chapter-specific guidelines for Chapter 19, Injury, Poisoning, and Certain Other Consequences of External Causes contain information about:

A) coding for osteoporosis and pathologic fractures
B) coding of reasons other than illness or injury for patient encounters, such as inoculations, vaccinations, contact or suspected exposure to disease, patient status, family or personal history of a medical condition
C) coding the cause of an injury or condition as related to outside causes, including use and sequencing of codes for external causes, place of occurrence, abuse, and acts of terrorism
D) coding injuries, fractures, burns, adverse effects, underdosing, poisoning, and toxic effects; a description of seventh-character extenders are included in this chapter

Question 32

Extenders are:

A) Codes that are unspecified or are most often used with a condition
B) Alphabetic seventh characters used to complete the description of many codes by conveying additional information
C) Codes located directly behind the main term and used only when the documentation has no additional detail on the condition or disease
D) An "x" placed in the fourth-, fifth-, or sixth-character place when needed to enable the seventh character to remain in the seventh-character position

Question 33

The condition produced after the initial injury or condition has been healed is called the:

A) Sequela
B) Subsequent effect
C) Last effect
D) Succession effect

Question 34

A placeholder character is:

A) Codes that are unspecified or are most often used with a condition
B) An "x" placed in the fourth-, fifth-, or sixth-character place when needed to enable the seventh character to remain in the seventh-character position
C) Alphabetic seventh characters used to complete the description of many codes by conveying additional information
D) Codes located directly behind the main term and used only when the documentation has no additional detail on the condition or disease

Question 35

Select the true statement regarding the first-listed diagnosis:

A) It is the reason for the visit and is used for provider/outpatient coding
B) It is the reason for the visit and is used for facility coding
C) It is the principal diagnosis and is used for facility coding
D) It is the reason for admission after study and is used for provider/outpatient coding

Question 36

Chapter 15 of the ICD-10-CM manual contains guidelines about:

A) General perinatal rules and sequencing
B) The use of symptom codes with and without definitive diagnosis codes and the use of coma scale codes
C) General rules for obstetric care and coding and sequencing instructions for fetal conditions affecting management of pregnancy, fetal extensions, HIV infection in pregnancy, normal delivery and postpartum conditions, and abortions
D) Rules for coding, use of the codes as first-listed or secondary codes, and assignment of additional codes to further define the condition

Question 37

This is the connecting term between the subterms acute and chronic to indicate ICD-10-CM provides a combination code to describe both conditions:

A) with
B) and
C) also
D) from

Question 38

Karen is an existing patient who routinely sees Dr. Horn for treatment of her chronic arthritis. Today, Karen presents for an emergency appointment due to painful urination, pain in the lower abdominal region, and chills. Dr. Horn performs a urinalysis which is positive for an infection of the urinary tract. Karen is given a prescription for a 10-day antibiotic and told to follow up if symptoms have not improved after taking the full prescription. Based on this diagnostic information, the coder would assign codes for:

A) Chronic arthritis
B) Painful urination, pain in the cervical region, chills, and urinary tract infection
C) Chronic arthritis and urinary tract infection
D) Urinary tract infection

Question 39

The nomenclature "Open wound of elbow, forearm, and wrist with tendon involvement" may be selected when:

A) A wound of appropriate depth must be present on one of the following locations: the elbow, the forearm, or wrist
B) A wound of appropriate depth must be present on a minimum of the hand and wrist
C) A wound of appropriate depth is present on the elbow, a wound is present on the forearm, and a wound is present on the wrist
D) Wounds of appropriate depth must be present on a minimum of the forearm and wrist

Question 40

Guidelines including information about hypertension and hypertensive heart and kidney disease, cerebral infarction, stroke, cerebral vascular accident, late effects, and myocardial infarction are included in this chapter's specific guidelines:

A) Diseases of the Circulatory System
B) Endocrine, Nutritional, and Metabolic Diseases
C) Diseases of the Nervous System
D) Diseases of the Blood and Blood-Forming Organs and Certain Disorders Involving the Immune Mechanism

Question 41

In the index, what provides further clarification of the patient's condition?

A) Subterm
B) Symptom
C) Main term
D) Subcategory

Question 42

The conventions, general coding guidelines and chapter specific guidelines are located in Section _____ of the manual.

A) II
B) IV
C) I
D) III

Question 43

Which of the following is not a major step in locating the appropriate ICD-10-CM code?

A) Verify the code identified in the Alphabetic Index by checking it in the Tabular List
B) Select the appropriate default code listed in the Tabular List
C) Review all notes listed in the Alphabetic Index and Tabular List
D) Determine the main term(s) from the documentation

Question 44

Dizziness is an example of a:

A) Symptom
B) Sign
C) Qualifier
D) Root condition

Question 45

Guidelines for coding pressure ulcer stages are in this chapter:

A) Diseases of the Genitourinary System
B) Diseases of the Digestive System
C) Diseases of the Skin and Subcutaneous Tissue
D) Diseases of the Musculoskeletal System and Connective Tissue

Question 46

Sequela is:

A) the initial injury or condition
B) a condition that is averted due to medical intervention
C) a condition that causes a late effect
D) a condition produced after the initial injury or condition has healed

Question 47

In ICD-10-CM, the note indicating that the condition excluded is distinct from the code condition and is coded elsewhere in the manual but that it may be coded with the code condition during the same encounter is the:

A) Excludes A
B) Excludes 1
C) Excludes B
D) Excludes 2

Question 48

In the medical record, the patient is documented to have the following conditions: lower back pain, blood in the urine, and a kidney infection. The coder would assign ICD-10-CM code(s) for the following condition(s):

A) Blood in the urine and kidney infection
B) Blood in the urine only
C) Lower back pain and blood in the urine
D) Kidney infection only

Question 49

When a more specific code is not provided in the ICD manual, the abbreviation _______ is used.

A) SA
B) NOS
C) NEC
D) S

Question 50

On what date did the final implementation of ICD-10-CM take place?

A) October 15, 2015
B) October 1, 2014
C) October 1, 2015
D) October 30, 2014

Question 51

Guidelines for Chapter ______ contain information about the use of symptom codes with and without definitive diagnosis codes and the use of coma scale codes, as well as rules for sequencing SIRS not due to infection and a description of functional quadriplegia.

A) 19
B) 13
C) 17
D) 18

Question 52

The guidelines for Chapter 20, External Causes of Morbidity, include:

A) abuse
B) infection
C) poisoning
D) respiratory failure

Question 53

Mary is admitted to ABC Hospital with a chief complaint of chest pain. Upon review of several diagnostic tests, Mary's provider provides a diagnostic statement of acute myocardial infarction. The acute myocardial infarction will be documented as the:

A) principal diagnosis
B) supporting diagnosis
C) first-listed diagnosis
D) defining diagnosis

Question 54

October 1, 2015, the new Procedural Coding System (PCS) code manual became known as:

A) ICD-10-CM
B) ICD-9-CM
C) ICD-10-PCS
D) ICD-9-PCS

Question 55

There are currently no guidelines for these chapters in ICD-10-CM:

A) 7, 8, 10
B) 3, 5, 7
C) 3, 6, 7
D) 3, 8, 11

Question 56

The way the condition due to the underlying disease or condition presents itself is called the:

A) Sign
B) Symptom
C) Manifestation
D) Condition

Question 57

The diagnostic statement "Cholera" would be coded as:

A) A00.0 Cholera due to Vibrio cholerae, biovar cholerae
B) A00.1 Cholera due to Vibrio cholerae, biovar eltor
C) A00.9 Cholera, unspecified
D) There is not enough information provided to select a code

Question 58

Guidelines including information regarding the sequencing of comorbidities or complications, such as anemia or pathologic fractures, occur in the chapter-specific guidelines of which ICD-10-CM chapter?

A) External Causes of Morbidity
B) Diseases of the Musculoskeletal System and Connective Tissue
C) Endocrine, Nutritional, and Metabolic Diseases
D) Neoplasms

Question 59

In ICD-10-CM, the following notation indicates that a separate associated complication or comorbidity is present:

A) and
B) without
C) also
D) with

Question 60

The following are true of the 2018 edition of the CPC exam except:

A) The CPC exam given throughout the entire year of 2018 will be based on the current year ICD-10-manual
B) The CPC exam is based on the previous year ICD-10, CPT and HCPCS manuals
C) The CPC exam is based on the current year CPT manual
D) The CPC exam is based on the current year HCPCS manual

Question 61

What is the primary reason why coders should understand the format of the ICD-10-CM manual?

A) To assist other coders in appropriate code selection
B) To distinguish subterms from nomenclature in the Tabular List
C) To achieve accuracy and consistency in coding of the facility's procedures
D) To achieve accuracy and consistency in coding of the medical record

Question 62

In ICD-10-CM, alphabetic seventh characters used to complete the description of many codes by conveying additional information are the:

A) Extenders
B) Late effects
C) Sequela
D) Placeholders

Question 63

Which of the following statements best describes the entities that can utilize the ICD-10-CM manual?

A) It can be utilized by physician offices, collection agencies, and hospitals
B) It can be utilized by physician offices
C) It can be utilized by collection agencies and physician offices
D) It can be utilized by physician offices, hospitals, and outpatient clinics

Question 64

Stacey presents to the Emergency Room with severe abdominal cramping, nausea, and diarrhea, worsening over the last three hours. Stacey's 4-year-old daughter has stayed home from daycare the last two days with the stomach flu. Stacey also ate shellfish for dinner at a local seafood restaurant. After noting Stacey's signs and symptoms and performing a problem-focused examination, the ED physician was unable to make a definitive diagnosis regarding Stacey's stomach troubles. She did note, however, that Stacey's condition is "probable food poisoning." Based on outpatient coding guidelines, what diagnosis(es) may the ED coder assign for Stacey's encounter?

A) A code for food poisoning, unspecified
B) Codes for food poisoning, unspecified, severe abdominal cramping, nausea, and diarrhea
C) Codes for severe abdominal cramping, nausea, and diarrhea
D) Codes for severe abdominal cramping and diarrhea

Question 65

Identify the main term in this diagnostic statement: "Congenital atrial septal defect"

A) Defect
B) Congenital
C) Septal
D) Atrial

Question 66

In ICD-10-CM, an "x" placed in the fourth-, fifth-, or sixth-character place when needed to enable the seventh-character extender to remain in the seventh-character position is the:

A) Sequela character
B) Placeholder character
C) Alphanumeric character
D) Default character

Question 67

When a definitive diagnosis has not been made:

A) Providers cannot receive reimbursement for the service
B) Providers must use codes for symptoms only
C) Providers must perform more diagnostic tests to identify the underlying condition before selecting a code
D) Providers must use codes for signs and symptoms

Question 68

Donald was seen at Quick Care outpatient urgent care facility. He presented with a mild fever, chills, nausea, and sore throat. Upon examination and throat culture, Donald was diagnosed with Strep throat. Strep throat will be documented as the:

A) presenting diagnosis
B) supplemental diagnosis
C) first-listed diagnosis
D) principal diagnosis

Question 69

The provider's diagnostic statement, the term that identifies the patient's condition, injury, or disease, is known as the:

A) Main term
B) Subterm
C) Default code
D) Nonessential modifier

Question 70

A default code is one that:

A) Does not need to use seventh-character extenders
B) Requires further specificity before selection
C) Is the most often used with a condition
D) Contains more than four alphanumeric characters

Question 71

Providers will sometimes confuse impending or threatened conditions with:

A) First listed conditions
B) Late effect conditions
C) Sequela conditions
D) Probable conditions

Question 72

A "with" statement connecting the subterms acute and chronic indicates:

A) A combination code is provided for the acute and chronic conditions
B) These conditions may not be coded together
C) The acute condition must be coded first
D) Distinct codes are provided for each condition

Question 73

Which of the following statements is not true about the ICD-10-CM manual?

A) It includes diagnosis codes only
B) It is published in two sections
C) It is used by providers and facilities to identify why services were provided
D) It is published in a three-volume set

Question 74

A condition with slow onset and of long duration, even the lifetime of the patient, is known as a(n) ___________ condition.

A) genetic
B) acute
C) chronic
D) bacterial

Question 75

Mary is admitted to ABC Hospital with a chief complaint of chest pain. Upon review of several diagnostic tests, Mary's provider provides a diagnostic statement of acute myocardial infarction. The acute myocardial infarction will be documented as the:

A) defining diagnosis
B) supporting diagnosis
C) principal diagnosis
D) first-listed diagnosis

Question 76

In ICD-10-CM, the following notation indicates that a separate associated complication or comorbidity is present:

A) and
B) with
C) without
D) also

Question 77

Which of the following statements best describes the entities that can utilize the ICD-10-CM manual?

A) It can be utilized by collection agencies and physician offices
B) It can be utilized by physician offices, collection agencies, and hospitals
C) It can be utilized by physician offices, hospitals, and outpatient clinics
D) It can be utilized by physician offices

Question 78

The guidelines for Chapter 20, External Causes of Morbidity, include:

A) abuse
B) respiratory failure
C) poisoning
D) infection

Question 79

Impending or threatened conditions are:

A) Codes that are unspecified or are most often used with a condition
B) Specific diagnostic conditions whose codes are used only when the condition was averted due to medical intervention
C) Conditions produced after the initial injury or condition has healed
D) Codes located directly behind the main term and used only when the documentation has no additional detail on the condition or disease

Question 80

When a definitive diagnosis has not been made:

A) Providers must use codes for signs and symptoms
B) Providers must use codes for symptoms only
C) Providers must perform more diagnostic tests to identify the underlying condition before selecting a code
D) Providers cannot receive reimbursement for the service