UPDATE 2026/2027
Which of the following are permissible to code for SDS diagnoses? - Answers past conditions
that relate to the current visit
What report is the definitive authority on specimens taken out during surgery? - Answers
pathology report
When is it appropriate to use non physician notes as a source document for coding? - Answers
to code BMI for a patient with documented obesity
Which condition should be documented as to whether or not the condition is 'reducible'? -
Answers umbilical hernia
Coagulation and serology tests help determine: - Answers the amount of time it takes for
bleeding to stop
EGD is a: - Answers procedure
When does an ER coder report E/M codes? - Answers when the physician is employed by the
hospital
Which of the following is NOT a characteristic of a critical access hospital? - Answers it
provides at least 50% critical care services
Which setting uses APCs for Medicare reimbursement? - Answers same-day surgery
Outpatient coding conventions state that _________________ diagnoses may NOT be coded. -
Answers possible
What report is the official summary of the procedure performed, preoperative and post
operative diagnosis, and step by step details for the actual procedure and or surgery performed.
- Answers operative report
Where would you expect to find the following statement? "A C-shaped flap was made in a small
fashion below the transverse sinus with the base on the transverse sinus overlying the
cerebellum." - Answers operative report
Documentation of EBL 20cc refers to: - Answers blood loss during a procedure
___________ is a common abbreviation for the oral route of medication administration. - Answers
PO
_____________ is common abbreviation for no known allergies. - Answers NKA
Hospital outpatient coders are typically responsible for coding all outpatient accounts, which
, can include _______ services. - Answers ancillary
A patient who is not formally admitted to the hospital for treatment is known as an ____________.
- Answers outpatient
___________ patients are those who are having surgery as an outpatient. - Answers SDS
One step in coding ER visits is to check to see if a __________________ is needed on the
procedure code. - Answers modifier
NOt every hospital is paid on the _____ system - Answers APC
The Caldwell-Luc procedure is an eponym for a specific type of: - Answers sinusotomy
EMERGENCY ROOM REPORT
CHIEF COMPLAINT: Left hand injury.
HISTORY OF PRESENT ILLNESS: This 25-year-old male was carrying groceries in plastic bags
approximately 10 - 15 pounds in each hand and felt sudden pain in the dorsum of his left hand.
He put down the bag and noticed there was some swelling along his left fourth MCP on the
dorsal side. Patient notes that last week he was brought to the ER after being in an MVA with
question of a hand injury from holding onto the steering wheel. He was discharged from the ER
being told he had a strain. There were no fractures or ligament damage, this is per patient and
no old records are available. Patient is not having any numbness, tingling, or feeling of
weakness right now.
PAST MEDICAL HISTORY: Unremarkable except for the MVA.
CURRENT MEDICATIONS:Amoxicillin for an earinfection. He occasionally takes ibuprofen as
well.
ALLERGIES: NONE KNOWN.
PHYSICAL EXAM: Patient is a WN, WD - Answers S63.657A; S63.655A
99282
ICD-9-CM diagnosis code(s): 842.12, E819.0
ICD-10-CM diagnosis code(s): S66.514D, S66.517D, V49.9XXA
CPT code(s) with modifier, if applicable: 99282