CCS 1 - ICD-10-CM and ICD-10-PCS Final Exam Questions With Correct Answers

The first step in coding the principal diagnosis is to ____. - Answer C. review the medical record NOS codes should never be assigned when a more specific code is available. - Answer TRUE Which of the following statements is true of the ICD-10-PCS code structure? A. Codes are numeric. B. Codes are made up of seven characters and no decimal points C. Codes are alphanumeric and made up of four characters. D. Codes have a minimum of three characters, and up to four characters. - Answer B. Codes are made up of seven characters and no decimal points Accurate and ethical ICD-10-CM and ICD-10-PCS coding depends on correctly following which of the items below? A. All instructions in the coding manuals B. All official guidelines developed by the Cooperating Parties C. Coding advice published in the AHA Coding Clinic D. All of the above - Answer D. All of the above "Ruled out" indicates that a diagnosis is still considered to be possible. "Rule out" indicates that a diagnosis originally considered as likely is no longer a possibility. - Answer False Coding guideline "code, if applicable, any causal condition first", notes that this code may be assigned as a principle diagnosis, when the causal condition is unknown or not applicable. If a causal condition is known, then code for that condition should be sequenced as the _________ diagnosis. a. principle b. first-listed c. secondary d. both a and b are correct - Answer d. both a and b are correct A patient is admitted following a hip fracture, and a diagnosis of Parkinson's disease and type II diabetes mellitus on insulin are noted in the history and physical examination. Nursing notes indicate that the patient required additional care because of the Parkinson's disease, and because the insulin levels had to be monitored. Which of the following diagnosis(es) should be coded and reported? A. Hip fracture B. Parkinson's disease C. Type II diabetes mellitus D. All of the above - Answer D. All of the above "_____" is used in the Alphabetic Index to provide guidance when two conditions are related or have a causal relationship. A. due to B. see condition C. and D. see category - Answer A. due to What is the main term: Recurrent seizure - Answer seizure For inpatient coding, if the attending physician does not confirm the pathological or radiological findings, the coder may code the findings without additional confirmation. - Answer False The admission diagnosis must always be the same as the principal diagnosis for inpatient admissions. - Answer False Which of the following providers is ultimately responsible for the final diagnosis? A. Consultant B. Surgeon C. Attending physician D. All of the above - Answer C. Attending physician ICD-10-CM uses the letter "___" as a placeholder character at certain codes to allow for future expansion - Answer X An "excludes __" note means "not coded here." - Answer 1 ICD-10-CM codes contain a maximum of how many characters? A. Three B. Four C. Five D. Seven - Answer D. Seven The admitting diagnoses is usually a sign or a symptom. - Answer True Data elements in the UHDDS includes the admitting diagnosis. - Answer False Dual classification is used to describe the required assignment of two codes to provide information about both a manifestation and the associated underlying disease - Answer True If a diagnosis is documented as possible at the time of discharge from an inpatient stay, code the condition as if it exists - Answer True Where does a physician list the final diagnoses? A. Admission record (face sheet) B. Progress notes C. Discharge summary D. Any of the above - Answer D. Any of the above What does the word "and" mean when it appears in a code title, such as "Unspecified anomalies of face and neck"? A. The condition is present in both face and neck. B. The condition may be present in either the face or neck. C. The condition may be present in both the face and the neck, or in the face or in the neck. D. None of the above - Answer C. The condition may be present in both the face and the neck, or in the face or in the neck. The main terms usually are nouns and/or disease conditions. - Answer True Words such as "with," "in," "due to," and "associated with" are used to express the relationship between the main term or a subterm indicating an associated condition or etiology. - Answer True When you separate codes that are used to identify acute and chronic conditions, the acute code is sequenced first - Answer True Which type of instructional note is used in the Tabular List of Diseases to identify a code for a condition that is a manifestation of an underlying disease? A. Use additional code note. B. Code first underlying condition note. C. Code, if applicable, any causal condition first note. D. Inclusion and exclusion note - Answer B. Code first underlying condition note. If documentation from different physicians conflicts, what should the coder do? A. Query the attending physician for clarification. B. Assign the code for the consultant's diagnosis. C. Assign the code for the most recent diagnosis documented. D. Assign codes for all diagnoses documented, even if they conflict with one another. - Answer A. Query the attending physician for clarification. Principle diagnosis is defined as the condition after study to be chiefly responsible for occasioning the admission of the patient to the hospital for care - Answer True If administration of a medication is noted on the medication record, the coder may assign a diagnosis solely on the basis of medication administration. - Answer False A(n) _____ effect is a residual effect (condition produced) after the acute phase of an illness or injury has terminated A. combination B. acute C. late D. chronic - Answer C. late It is noted on a laboratory test result that a patient's sodium is below normal, so it is acceptable to code hyponatremia - Answer False ____________________ is (are) used in both the index and tabular to enclose supplementary words that may be present or absent in the statement of a disease or procedure, without affecting the code number to which it is assigned. a. "Excludes" b. Brackets c. "Includes" d. Parentheses - Answer d. Parentheses Which of the following procedures is an example of the "via natural or artificial opening endoscopic" ICD-10-PCS approach? A. Laparoscopic cholecystectomy B. Appendectomy C. Esophagogastroduodenoscopy D. Nasogastric tube insertion - Answer C. Esophagogastroduodenoscopy Which of the following is NOT part of the format of the ICD-10-PCS? A. Alphabetic Index B. Tables C. Body Part D. None of the above - Answer D. None of the above Which of the following is the main purpose of the ICD-10-PCS Alphabetic Index? A. To locate a complete ICD-10-PCS code B. To locate the appropriate table in which the information required to complete the characters in a code may found C. To identify appropriate root operations D. To find the valid combination of characters that make up a code - Answer B. To locate the appropriate table in which the information required to complete the characters in a code may found Which of the following statements is NOT one of the conditions that must be met in order for multiple procedures performed during the same operative episode to be coded separately? A. The same root operation is performed on different body parts as defined by distinct values of the body part character. B. The same root operation is repeated at different body sites that are included in the same body part value. C. Multiple root operations with the same objectives are performed on the same body part. D. The intended root operation is attempted using one approach but is converted to a different approach - Answer C. Multiple root operations with the same objectives are performed on the same body part. Which of the following characters within ICD-10-PCS is one of the most important concepts to understand in order to identify and select the correct code? A. Body Part B. Root Operation C. Device D. Qualifier - Answer B. Root Operation The majority of the ICD-10-PCS Official Coding Guidelines relate to which of the following ICD-10-PCS characters in a code? A. Root operation B. Approach C. Body Part D. Device - Answer A. Root operation Which of the following statements is NOT true about selection of ICD-10-PCS root operations? A. The coder is not required to query the physician when the correlation between the documentation and the defined ICD-10-PCS term is clear. B. It is the coder's responsibility to determine what ICD-10-PCS root operation definition equates to the physician documentation. C. The root operations used in ICD-10-PCS must match exactly with the physician documentation before the code may be selected. D. Root operation refers to the objective of the procedure. - Answer C. The root operations used in ICD-10-PCS must match exactly with the physician documentation before the code may be selected What is the correct root operation for an application of a compression dressing to an abdominal wound? A. Excision B. Resection C. Detachment D. Extraction - Answer B. Resection