CCA Exam Questions and Correct Answers
ICD-10-CM
report diagnoses.
ICD-10-PCS
inpatient hospital procedures only.
CPT codes
physician and outpatient procedure
HCPCS Level II codes
supplies and services not included in CPT
Always begin diagnosis code lookup in
Alphabetic Index.
A category code contains
3 characters
Laterality
identifies which side of the body is affected.
"Code First"
the underlying condition is sequenced first.
"Use Additional Code"
,another code is needed
Excludes1
conditions generally should NOT be coded together.
Excludes2
both conditions MAY be coded together
NEC
Not Elsewhere Classified
NOS
Not Otherwise Specified
Manifestation codes
conditions caused by another disease.
"In diseases classified elsewhere"
indicates a manifestation code.
For outpatient encounters, do NOT code uncertain diagnoses.
Probable
Possible
Suspected
Rule Out
A principal diagnosis
, the condition chiefly responsible for the admission (inpatient). (first-listed)
Acute conditions generally receive
priority over chronic conditions when both are documented and there are no guideline
exceptions.
"History of"
the condition is no longer active.
"Status post (S/P)"
after or following
(Status post knee replacement
Means the surgery occurred previously.)
Sequela
a late effect of a previous condition or injury.
(Scar following a burn
Weakness after a stroke)
Combination codes
report more than one condition with a single code.
HIM professionals
manage the accuracy , security, accessibility, and integrity of health information.
(Purpose:
Protect patient information
ICD-10-CM
report diagnoses.
ICD-10-PCS
inpatient hospital procedures only.
CPT codes
physician and outpatient procedure
HCPCS Level II codes
supplies and services not included in CPT
Always begin diagnosis code lookup in
Alphabetic Index.
A category code contains
3 characters
Laterality
identifies which side of the body is affected.
"Code First"
the underlying condition is sequenced first.
"Use Additional Code"
,another code is needed
Excludes1
conditions generally should NOT be coded together.
Excludes2
both conditions MAY be coded together
NEC
Not Elsewhere Classified
NOS
Not Otherwise Specified
Manifestation codes
conditions caused by another disease.
"In diseases classified elsewhere"
indicates a manifestation code.
For outpatient encounters, do NOT code uncertain diagnoses.
Probable
Possible
Suspected
Rule Out
A principal diagnosis
, the condition chiefly responsible for the admission (inpatient). (first-listed)
Acute conditions generally receive
priority over chronic conditions when both are documented and there are no guideline
exceptions.
"History of"
the condition is no longer active.
"Status post (S/P)"
after or following
(Status post knee replacement
Means the surgery occurred previously.)
Sequela
a late effect of a previous condition or injury.
(Scar following a burn
Weakness after a stroke)
Combination codes
report more than one condition with a single code.
HIM professionals
manage the accuracy , security, accessibility, and integrity of health information.
(Purpose:
Protect patient information
