MEDICAL CODING AND
REIMBURSEMENT STUDY GUIDE,
TEST 1 QUESTIONS AND ANSWERS
What is found in a health record? - Answer-face sheet: demographic information and
summary information
history and physical: determines diagnosis, contains chief complaints, symptoms
family history
operative report
progress notes: contains diagnosis and procedures
consultation report
discharge summary:final diagnosis, complications, procedure performed, follow-up
care info
What term do you look up in the tabular list? - Answer-main term
How do we determine the code of the principal diagnosis? - Answer-In determining
principal diagnosis, coding conventions in the ICD-10-CM, the Tabular List and
Alphabetic Index take precedence over these official coding guidelines.
What governs the selection of a principal diagnosis? - Answer-the circumstance of
the encounter
What is the definition of the principal diagnosis? - Answer-Condition established after
study to be chiefly responsible for occasioning the encounter
Which code should be sequenced first when there are two or more diagnoses that
equally meet the definition for principal diagnosis? - Answer-Either may be
sequenced first
What would the principal diagnosis be when a patient is admitted for treatment that is
not carried out? - Answer-The condition which after study occasioned the admission
to the hospital
How would you code a diagnosis documented at discharge as "probable",
"suspected", "still to be ruled out", etc? - Answer-Code as if it existed or was
established
What is the definition of additional (secondary) diagnoses? - Answer-All conditions
that coexist at the time of admission, that develop subsequently, or that affect
treatment received and/or length of stay
When can History codes be used a secondary codes? - Answer-If the historical
condition or family history impacts current care or influences treatment
Which is the principal diagnosis for the following scenario? "Patient presents with
abdominal pain and nausea due to gastric ulcer" - Answer-gastric ulcer
, Which is the principal diagnosis for the following scenario? "Patient presents with
dizziness and chest pain due to acute myocardial infarction" - Answer-myocardial
infarction
According to the ICD-10-CM coding conventions, parentheses ( ) - Answer-enclose
terms known as non-essential modifiers
In regard to etiology and manifestation codes, the ICD-10-CM coding conventions
instruct that - Answer-Codes should be listed together with the underlying condition
coded first followed by the manifestation code
What is medical coding? - Answer-medical coding is the assignment of numerical
and alphanumerical codes to represent the diagnoses and procedures provided to
patient during an episode of care.
What is considered a primary source in the medical field? - Answer-patients health
record
What is a CCA? - Answer-A Certified Coding Associate can code in any setting,
including both hospitals and physician practices.
What is a CCS? - Answer-A Certified Coding Specialist that can classify medical
data from patient records, generally in a hospital setting. They are knowledgeable in
medical terminology, disease processes and pharmacology.
What is a CCS-P? - Answer-A Certified Coding Specialist- Physician Based and they
code in a physician setting. They know the CPT-coding system and has familiarity
with the ICD-10-CM and HCPCS level 2 coding system.
What is a CPC? - Answer-A Certified Professional Coder. They are the most
recognized medical coding certification in the healthcare industry. The CPC is the
gold standard for medical coding in a physician office setting.
What are the laws medical coders deal with on a regular basis? (NW interview) -
Answer-HIPPA because they handle patients identification and medical records.
Confidentiality is very important!
What is the significance of the medical coders job? (NW interview) - Answer-It is the
way a hospital or physician practice gets paid.
What's difficult about coding? (NW interview) - Answer-Two different coders can
come up with two different codes that can both be correct.
What applications do coders most often use? (NW interview) - Answer-EPIC, 3M,
Microsoft Outlook, and Google
When did the U.S. adopt the ICD-10 coding system? - Answer-October 1, 2015
REIMBURSEMENT STUDY GUIDE,
TEST 1 QUESTIONS AND ANSWERS
What is found in a health record? - Answer-face sheet: demographic information and
summary information
history and physical: determines diagnosis, contains chief complaints, symptoms
family history
operative report
progress notes: contains diagnosis and procedures
consultation report
discharge summary:final diagnosis, complications, procedure performed, follow-up
care info
What term do you look up in the tabular list? - Answer-main term
How do we determine the code of the principal diagnosis? - Answer-In determining
principal diagnosis, coding conventions in the ICD-10-CM, the Tabular List and
Alphabetic Index take precedence over these official coding guidelines.
What governs the selection of a principal diagnosis? - Answer-the circumstance of
the encounter
What is the definition of the principal diagnosis? - Answer-Condition established after
study to be chiefly responsible for occasioning the encounter
Which code should be sequenced first when there are two or more diagnoses that
equally meet the definition for principal diagnosis? - Answer-Either may be
sequenced first
What would the principal diagnosis be when a patient is admitted for treatment that is
not carried out? - Answer-The condition which after study occasioned the admission
to the hospital
How would you code a diagnosis documented at discharge as "probable",
"suspected", "still to be ruled out", etc? - Answer-Code as if it existed or was
established
What is the definition of additional (secondary) diagnoses? - Answer-All conditions
that coexist at the time of admission, that develop subsequently, or that affect
treatment received and/or length of stay
When can History codes be used a secondary codes? - Answer-If the historical
condition or family history impacts current care or influences treatment
Which is the principal diagnosis for the following scenario? "Patient presents with
abdominal pain and nausea due to gastric ulcer" - Answer-gastric ulcer
, Which is the principal diagnosis for the following scenario? "Patient presents with
dizziness and chest pain due to acute myocardial infarction" - Answer-myocardial
infarction
According to the ICD-10-CM coding conventions, parentheses ( ) - Answer-enclose
terms known as non-essential modifiers
In regard to etiology and manifestation codes, the ICD-10-CM coding conventions
instruct that - Answer-Codes should be listed together with the underlying condition
coded first followed by the manifestation code
What is medical coding? - Answer-medical coding is the assignment of numerical
and alphanumerical codes to represent the diagnoses and procedures provided to
patient during an episode of care.
What is considered a primary source in the medical field? - Answer-patients health
record
What is a CCA? - Answer-A Certified Coding Associate can code in any setting,
including both hospitals and physician practices.
What is a CCS? - Answer-A Certified Coding Specialist that can classify medical
data from patient records, generally in a hospital setting. They are knowledgeable in
medical terminology, disease processes and pharmacology.
What is a CCS-P? - Answer-A Certified Coding Specialist- Physician Based and they
code in a physician setting. They know the CPT-coding system and has familiarity
with the ICD-10-CM and HCPCS level 2 coding system.
What is a CPC? - Answer-A Certified Professional Coder. They are the most
recognized medical coding certification in the healthcare industry. The CPC is the
gold standard for medical coding in a physician office setting.
What are the laws medical coders deal with on a regular basis? (NW interview) -
Answer-HIPPA because they handle patients identification and medical records.
Confidentiality is very important!
What is the significance of the medical coders job? (NW interview) - Answer-It is the
way a hospital or physician practice gets paid.
What's difficult about coding? (NW interview) - Answer-Two different coders can
come up with two different codes that can both be correct.
What applications do coders most often use? (NW interview) - Answer-EPIC, 3M,
Microsoft Outlook, and Google
When did the U.S. adopt the ICD-10 coding system? - Answer-October 1, 2015
