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MED112 CODE/BILL

MED112 CH 04 SB DIAGNOSTIC CODING: ICD-10-CM

QuestionAnswer
MED112 CH 04 SB
ICD-10-CM is used to code and classify ______ from patient medical records, physician offices, and surveys conducted by the National Center for Health Statistics (NCHS). A. procedures B. ICD-9 codes C. morbidity data D. historical data morbidity data
Centers for Medicare and Medicaid Services (CMS) rules state that a Medicare claim will be ______ when the most specific code available is not used. A. pending B. delayed C. rejected D. accepted rejected
______ codes must be used as of the date they go into effect, and invalid (deleted) codes must not be used. A. New B. Revised C. Obsolete D. Invalid New
ICD-10-CM's first part also has three additional sections that provide resources for researching correct codes. Which of the following are those three sections? A. ICD-10-CM Table of Drugs and Chemicals B. ICD-10-CM Tabular List of Diseases and Injuries C. ICD-10-CM Neoplasm Table D. ICD-10-CM Index to External Causes E. ICD-10-CM Index to Diseases and Injuries A. ICD-10-CM Table of Drugs and Chemicals C. ICD-10-CM Neoplasm Table D. ICD-10-CM Index to External Causes
Which index contains all the medical terms in the Tabular List classifications and, for some conditions, also lists common terms that are not found in the Tabular List? A. ICD-10-CM B. Alphabetical Index C. Tabular Index D. Diagnostic Index Alphabetical Index
Under HIPAA, the diagnosis codes that must be used in the United States starting on October 1, 2015, are based on the International Classification of Diseases (ICD), ______ Revision. A. 7th B. 10th C. 11th D. 9th 10th
In ICD-10-CM, a code is a ______ character alphanumeric representation of a disease or condition. A. three- to seven- B. three- to six- C. two- to seven- D. three- to eight- three- to seven-
Which of these help to point to the correct term but do not have to appear in the physician's diagnostic statement for the coder to correctly select the code? A. Subterms B. Main terms C. Nonessential modifiers D. Essential modifiers Nonessential modifiers
Which types of codes are posted on the appropriate websites, such as the National Center for Health Statistics and Centers for Medicare and Medicaid Services (CMS) websites? A. Revised B. Invalid C. Major new D. Valid A. Revised B. Invalid C. Major new
When a(n) ______ is listed in the Alphabetic Index, it is often cross-referenced with the accepted medical term. A. eponym B. subterm C. main term D. common term common term
Select all of the following that are the major parts of the ICD-10-CM coding manual. A. ICD-10-CM Index to Diseases and Injuries B. ICD-10-CM Disease Labels C. ICD-10-CM Table of Procedures D. ICD-10-CM Tabular List of Diseases and Injuries A. ICD-10-CM Index to Diseases and Injuries D. ICD-10-CM Tabular List of Diseases and Injuries
A(n) ______ is usually listed under both that name and the main term disease or syndrome. A. eponym B. main term C. subterm D. nonessential modifier eponym
The Alphabetic Index is organized by the ______. A. location B. subterm C. condition D. body part condition
If the main term or subterm is too long to fit on one line, as is often the case when many nonessential modifiers appear, what kind of lines are used? (More than one answer may be correct) A. Turnover B. Cross-over C. Cross-reference D. Carryover A. Turnover D. Carryover
If the ______ see appears after a main term, the coder must look up the term that follows the word see in the index. A. subterm B. eponym C. main term D. cross-reference cross-reference
The first step in the assignment of the correct code is to look up the ______ that describes the patient's condition based on the diagnostic statement. A. medical term B. tabular index C. default code D. alphabetical term medical term
Which abbreviation means that no code matches the exact situation? A. NOC B. NEC C. NES D. NOS NEC
Many terms appear more than once in the Alphabetic Index and are known as ______. A. eponyms B. common terms C. main terms D. subterms common terms
An eponym is a condition or procedure named for a person, such as which of the following? A. The manufacturer of the drug used to treat it B. A patient C. The physician who invented it D. The physician who discovered it B. A patient C. The physician who invented it D. The physician who discovered it
Some conditions may require two codes: one for the ______ and a second for the ______. A. etiology; manifestation B. manifestation; eponym C. etiology; subterm D. main term; subterm etiology; manifestation
Turnover lines are always ______ than the subterms. A. indented farther to the left B. aligned farther to the right C. indented farther to the right D. aligned farther to the left indented farther to the right
The ______ received its name from the language of statistics, and it means to count, record, or list systematically. A. Alphabetic Index B. Tabular List C. eponym D. main term Tabular List
______, which is a type of cross-reference, points the coder to additional, related index entries, indicating that the coder should review the additional categories that are mentioned. A. See B. See also C. See additional D. See another See also
A ______ is a four- or five-character alphanumeric subdivision of a category that provides a further breakdown of the disease to show its etiology, site, or manifestation. A. placeholder B. category code C. subcategory D. code subcategory
Which abbreviation indicates that the code to be located in the Tabular List should be used when a condition is not completely described in the medical record? A. NEC B. NOC C. NES D. NOS NOS
Which word or phrase heads inclusion notes? A. See also B. Includes C. Cross-reference D. See Includes
______ means “not included here,” but a patient could have both conditions at the same time. A. Includes 1 B. Includes 2 C. Excludes 2 D. Excludes 1 Excludes 2
The use of ______ in the Alphabetic Index around a code means that it cannot be the first-listed code in coding the diagnostic statement. A. parentheses B. italics C. brackets D. bolded text brackets
NEC and NOS are used in the ______ with the same meanings as in the Alphabetic Index. A. Neoplasm Table B. Disease Index C. Tabular List D. exclusion Notes Tabular List
The diseases and injuries in the Tabular List are organized into chapters according to which of the following? A. Body system B. Purpose C. Eponym D. Etiology A. Body system B. Purpose D. Etiology
The ______ code may be followed by the instruction "use an additional code" or a note saying the same thing. A. etiology B. category C. additional D. manifestation etiology
A category is a ______-character alphanumeric code that covers a single disease or related condition. A. five B. four C. six D. three three
In ICD-10-CM, the idea that the classification system should capture the side of the body that is documented for a particular condition is called ______. A. etiology B. manifestation C. causation D. laterality laterality
______ notes are headed by the term includes and refine the content of the category appearing above them. A. See all B. Exclusion C. Guideline D. Inclusion Inclusion
The Official Guidelines has sections for which of the following? A. Outpatient coding B. General rules C. Surgical coding D. Inpatient coding A. Outpatient coding B. General rules D. Inpatient coding
______ is used when two conditions could not exist together, such as an acquired and a congenital condition; it means “not coded here.” A. Includes 1 B. Excludes 2 C. Excludes 1 D. Includes 2 Excludes 1
______ conditions may be related to the primary diagnosis, or they may involve a separate illness that the physician diagnoses and treats during the encounter. A. Coexisting B. Underlying C. Overreaching D. Individual Coexisting
Chronic conditions are those that continue over a long period of time or recur ______. A. rapidly B. frequently C. occasionally D. suddenly frequently
Which of the following are true about sequelae? A. The code for the acute illness that led to the sequela is never used with a code for the late effect itself. B. The main term sequela is followed by subterms that list the causes. C. Two codes are usually not required. D. Two codes are usually required. A. The code for the acute illness that led to the sequela is never used with a code for the late effect itself. B. The main term sequela is followed by subterms that list the causes. D. Two codes are usually required.
If a condition is documented as bilateral but there is no appropriate ICD-10-CM code for bilaterality, how many codes are assigned? A. One B. None C. Three D. Two Two
______ are not always established at a first encounter. A. Physician notes B. Diagnostic codes C. Symptoms D. Diagnoses Diagnoses
The ICD-10-CM Official Guidelines for Coding and Reporting, also known as the Official Guidelines, are rules developed by which of the following cooperating parties? A. American Hospital Association (AHA) B. Patient advocates from various facilities C. CMS advisers D. American Health Information Management Association (AHIMA) E. NCHS A. American Hospital Association (AHA) C. CMS advisers D. American Health Information Management Association (AHIMA) E. NCHS
ICD-10-CM code for the primary diagnosis is listed ______. A. on admission B. first C. second D. last first
Which of the following are used when coding in the outpatient (physician practice) setting? A. Reported symptoms B. Rule out diagnoses C. Probabilities D. Suspicions Reported symptoms
Acute symptoms generally are relatively ______ or severe in nature. A. sudden B. lifelong C. frequent D. continuous sudden
Using the most specific code possible is referred to as what? A. Coding the assumptions B. Coding to the highest level of specificity C. Coding to the lowest level of specificity D. Coding the specific signs and symptoms Coding to the highest level of specificity
Sequelae are conditions that remain after a patient's acute illness or injury has ______. A. begun B. continued C. started D. ended ended
Which of the following codes are classified in Chapter 1 of ICD-10-CM's Tabular List? A. Hereditary diseases B. Parasitic diseases C. Congenital diseases D. Infectious diseases B. Parasitic diseases D. Infectious diseases
Although possible diagnoses may appear in the physician's documentation as diagnostic work is progressing, these inconclusive diagnoses are ______ to determine the first-listed codes reported for reimbursement of service fees. A. not used B. locked in C. always used D. sometimes used not used
With what does diagnosis coding begin in outpatient settings? A. Patient's chief complaint B. Results of laboratory findings C. Doctor's assessment D. Patient's vital signs Patient's chief complaint
Coding diagnoses are based on the physician's diagnosis or diagnoses. This information may be located on which of the following documents? A. Claim form B. Patient's statement C. Encounter form D. Progress notes C. Encounter form D. Progress notes
For hospital coding, the first-listed diagnosis is referred to as the ______ diagnosis and is defined as the condition established after study to be chiefly responsible for the admission. A. admitting B. tertiary C. principal D. secondary principal
What is the third step in outpatient diagnosis coding? A. Locate the main term in the Alphabetic Index. B. Check compliance with any applicable official guidelines and list codes in appropriate order. C. Identify the main term for each condition. D. Verify the code in the Tabular List. Identify the main term for each condition.
When coding to the highest level of specificity, it is important to have the proper ______ to support the detail. A. education B. signs and symptoms C. specifics D. documentation documentation
What is the fourth step in outpatient diagnosis coding? A. Identify the main term for each condition. B. Verify the code in the Tabular List. C. Locate the main term in the Alphabetic Index. D. Review complete medical documentation. Locate the main term in the Alphabetic Index.
Chapter ______ of ICD-10-CM's Tabular List classifies communicable infectious and parasitic diseases. A. 4 B. 1 C. 3 D. 2 1
Which of the following are guidelines observed to verify the selection of the correct code in the Tabular List? A. List multiple codes in the correct order. B. Be alert for and follow instructions for additional digit requirements. C. Read and follow any notes below the main term. D. Follow any instructions requiring the selection of additional codes. E. Read includes or excludes notes, checking back to see if any apply to the code's category, section, or chapter. A. List multiple codes in the correct order. B. Be alert for and follow instructions for additional digit requirements. D. Follow any instructions requiring the selection of additional codes. E. Read includes or excludes notes, checking back to see if any apply to the code's category, section, or chapter.
What is the first step in outpatient diagnosis coding? A. Identify the main term for each condition. B. Locate the main term in the Alphabetic Index. C. Abstract the medical conditions from the visit documentation. D. Review complete medical documentation. Review complete medical documentation.
Coders should be sure not to include ______ (for outpatient settings) and to report the primary diagnosis as the first-listed code followed by any coexisting conditions and external source codes. A. patient symptoms B. suspected conditions C. the definitive diagnosis D. patient signs suspected conditions
What is the second step in outpatient diagnosis coding? A. Review complete medical documentation. B. Identify the main term for each condition. C. Abstract the medical conditions from the visit documentation. D. Check compliance with any applicable official guidelines and list codes in appropriate order. Abstract the medical conditions from the visit documentation.
The ICD-10-CM offers which of the following for expanded detail? A. Extensions B. Additional characters C. Higher level of specificity D. More modifiers A. Extensions B. Additional characters C. Higher level of specificity
Where do you find the main term for the patient's primary diagnosis? A. Tabular List B. Tabular Index C. Alphabetic Index D. Alphanumeric Index Alphabetic Index
ICD-10-CM contains ______ chapters, whereas ICD-9-CM contains ______ chapters. A. 17; 21 B. 21; 17 C. 25; 15 D. 11; 18 21; 17
What is the fifth step in outpatient diagnosis coding? A. Identify the main term for each condition. B. Locate the main term in the Alphabetic Index. C. Verify the code in the Tabular List. D. Verify the code matches the documentation. Verify the code in the Tabular List.
What can be used in a situation in which an old claim resurfaces and requires coders to research an ICD-9-CM code? A. ICD-10-CM code index B. Generic equivalence mappings C. General inequivalent mappings D. General equivalence mappings General equivalence mappings
What is the sixth step in outpatient diagnosis coding? A. Identify the main term for each condition. B. Locate the main term in the Alphabetic Index. C. Check compliance with any applicable official guidelines and list codes in appropriate order. D. Verify and confirm the code in the Tabular List. Check compliance with any applicable official guidelines and list codes in appropriate order.
The major advantages that ICD-10-CM provides are many more ______ for disease and other health-related conditions and much greater flexibility for adding new codes in the future. A. conditions B. subcategories C. main terms D. categories categories
Which of the following applies to ICD-10-CM? (More than one answer may be correct.) A. The codes are alphanumeric with five, six, or seven digits. B. There are a maximum of five characters. C. It contains 17 chapters. D. It contains 21 chapters. E. The order of the chapters is the same as it is for ICD-9. A. The codes are alphanumeric with five, six, or seven digits. D. It contains 21 chapters.
The American Association of Professional Coders (AAPC) website offers what kind of tool to differentiate between ICD-9-CM and ICD-10-CM codes? A. Equivalent sets B. Inequivalent sets C. Mappings D. Conversion Conversion
ICD-10-CM CHAPTERS A00-B99 Certain infectious and parasitic diseases
ICD-10-CM CHAPTERS C00-D49 Neoplasms
ICD-10-CM CHAPTERS D50-D89 Diseases of the blood and blood-forming organs and certain disorders involving the immune mechanism
ICD-10-CM CHAPTERS E00-E89 Endocrine, nutritional, and metabolic diseases
ICD-10-CM CHAPTERS F01-F99 Mental and behavioral disorders
ICD-10-CM CHAPTERS G00-G99 Diseases of the nervous system
ICD-10-CM CHAPTERS H00-H59 Diseases of the eye and adnexa
ICD-10-CM CHAPTERS H60-H95 Diseases of the ear and mastoid process
ICD-10-CM CHAPTERS I00-199 Diseases of the circulatory system
ICD-10-CM CHAPTERS J00-J99 Diseases of the respiratory system
ICD-10-CM CHAPTERS K00-K95 Diseases of the digestive system
ICD-10-CM CHAPTERS L00-L99 Diseases of the skin and subcutaneous tissue
ICD-10-CM CHAPTERS M00-M99 Diseases of the musculoskeletal system and connective tissue
ICD-10-CM CHAPTERS N00-N99 Diseases of the genitourinary system
ICD-10-CM CHAPTERS O00-O9A Pregnancy, childbirth, and the puerperium
ICD-10-CM CHAPTERS P00-P96 Certain conditions originating in the perinatal period
ICD-10-CM CHAPTERS Q00-Q99 Congenital malformations, deformations, and chromosomal abnormalities
ICD-10-CM CHAPTERS R00-R99 Symptoms, signs, and abnormal clinical and laboratory findings, not elsewhere classified
ICD-10-CM CHAPTERS S00-T88 Injury, poisoning, and certain other consequences of external causes
ICD-10-CM CHAPTERS V00-Y99 External causes of morbidity
ICD-10-CM CHAPTERS Z00-Z99 Factors influencing health status and contact with health services
ICD-10-CM CHAPTERS U00-U85 Codes for special purposes
Which of the following are used to report encounters for circumstances other than a disease or injury in ICD-10-CM? A. V codes B. A codes C. Z codes D. E codes Z codes
The ICD-10-CM updates released by the National Center for Health Statistics are called ____. A. addenda B. sequelae C. eponyms D. conventions addenda
The ICD-10-CM code set contains approximately _____ codes, making it much larger than ICD-9-CM. A. 57,000 B. 13,000 C. 70,000 D. 3,250,000 70,000
A(n) ____ is an objective indication that can be evaluated by a physician. A. sequela B. eponym C. sign D. symptom sign
ICD-10-CM uses __________Blank to indicate an incomplete term. A. parentheses B. brackets C. abbreviations D. colons colons
Which of the following is not a further breakdown of a disease that may be provided by a subcategory? A. sequela B. manifestation C. etiology D. site sequela
Typographic techniques that provide visual guidance for understanding information and help coders to understand rules and select the right code are known as __________Blank in ICD-10-CM. A. sequelae B. inclusion notes C. conventions D. manifestations conventions
Tay-Sachs disease is an example of a(n) __________Blank. Multiple Choice A. etiology B. eponym C. manifestation D. convention eponym
The abbreviation ___ is used with a term when there is no code that is specific for the condition. A. GEM B. NEC C. CC D. NOS NEC
Refers to a code that should be used for an incompletely described condition Unspecified
Annual updates to the ICD-10-CM diagnostic coding system Addenda
A nonessential word or phrase that helps define a diagnosis code Supplementary
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