EXAM QUESTIONS AND
ANSWERS
Whatisclinicalcoding?-
Correctanswer~Clinicalcodingisthetranslationofmedicalterminologythatdescribesapatient'sc
omplaint,problem,diagnosis,treatmentorotherreasonforseekingmedicalattentionintocodesth
atcanthenbeeasilytabulated,aggregatedandsortedforstatisticalanalysisinanefficientandmeani
ngfulmanner.
Whatiscodinguniformityandwhyisitimportant?-
Correctanswer~Uniformitymeansthatwheneveragivenconditionorreasonforanepisodeiscode
d,thesamecodeisalwaysusedtorepresentthatconditionorreasonfortheencounter.Uniformityis
essentialiftheinformationistobeusefulandcomparable
Whatarethethreedimensionsofcodingaccuracy?-Correctanswer~Individualcodes
Totalityofcodes
Sequencingofcodes
WhatismeantbyIndividualcodes?-
Correctanswer~Eachclinicalstatementofdiagnosismusthavethecorrectcodeassignment.Anindi
vidualpatientmayhavemanydiagnoses(orprocedures).Consequentlyacodedrecordforanepisod
ewillhaveatleastoneorpotentiallymanyindividualcodes.
,Whatismeantbytotalityofcodesandwhyisthisimportant?-
Correctanswer~Theconceptoftotalityofcodesiscomplex.Itmeansthatallcodesnecessarytogivea
naccurateclinicalpictureofthepatient'sdiagnosis,problemsorotherreasonsforanepisodeencou
nter,mustbeassignedinaccordancewiththerules,conventionsandstandardsoftheclassification.T
hisisimportantasitispossibleforalistofcodestodescribeanepisodeincorrectlyintermsofclinicalco
dingrulesandstandardseventhoughtheindividualcodesselectedarecorrect.
Whatismeantbysequencingofcodes,whyisthisimportantandwhatisasignificantaspectofthis?-
Correctanswer~Codesmustbesequencedinaccordancewithclinicalcodingstandardstoprovidec
onsistentdataforstatisticalanalysis.Asignificantaspectofsequencingistheselectionofthemainco
nditiontreated
Howmanystepsmakeupthecodingprocess?-Correctanswer~Four
Whatissteponeofthefourstepcodingprocess?-Correctanswer~StepOne
Analysemedicalterminologytodetermineleadterm(s)andmodifier(s)
Whatissteptwoofthefourstepcodingprocess?-Correctanswer~StepTwo
Locatetheleadterm(s)intheAlphabeticalIndex(ICD-10Volume3)
Whatisstepthreeofthefourstepcodingprocess?-Correctanswer~StepThree
Assignatentativecode(s)usingtheAlphabeticalIndexandtakingintoaccountallrules,conventions
andstandards.
Whatisstepfourofthefourstepcodingprocess?-Correctanswer~StepFour
Verifythecode(s)usingtheTabularList(ICD-
10Volume1)andtakingintoaccountinstructionalnotes.
, Ifthereisadoubtastowhereaconditionshouldbecoded,whatchaptersmusttakepriority?-
Correctanswer~The'specialgroup'chaptersmusttakepriority.
HowmanychaptersmakeupICD-10?-Correctanswer~22chapters
NamethetypesofchapterswithinICD-
10,describebrieflytheircontentandgivethechapternumbersthatfallwithineachtype.-
Correctanswer~Specialgroupchapters
ChaptersI-V,XV-
XVIIandXIXclassifyconditionsthatdonotfocusonanyonebodysystem.Ingeneral,conditionsarepri
marilyclassifiedtooneofthe'specialgroup'chapters.
Bodysystemchapters
ChaptersVI-XIVclassifyconditionsaccordingtothebodysystemtheyaffect.
Otherchapters
ChaptersXVIIIandXX-
XXIIclassifyotherdisordersandfactorswhichdonotsitcomfortablyineitheraspecialgrouporbodys
ystemchapter
Whatcharacterlevelsmustcodeassignmentbemadeto,withinICD-10,tomakethecodevalid?-
Correctanswer~Codeassignmentmustalwaysbemadetofourcharacterlevelorfivecharacterlevel
(whereavailableandinlinewithfifthcharactercodingstandards),forthecodetobevalid
Describewhatmustbedonewhenathreecharactercodedoesnothavefourthcharactersubdivision
sandwhythisis.-
Correctanswer~Whereathreecharactercategorycodeisnotsubdividedintofourcharactersubdivi
sionsthe'X'fillermustbeassignedinthefourthcharacterfieldsothecodesareofastandardlengthfor
dataprocessingandvalidation.Thecodeisstillconsideredathreecharactercodefromaclassificatio
nperspective.
Whereathreecharactercoderequiresassignmentofboththe'X'fillerandafifthcharactersubdivisio
n,the'X'fillermustcontinuetoberecordedinthefourthfieldbeforethefifthcharacter.