HIM 252 EXAM 1 UPDATED ACTUAL QUESTIONS AND CORRECT ANSWERS

HIM 252 EXAM 1 UPDATED ACTUAL QUESTIONS AND
CORRECT ANSWERS

Question:
1. Which 2 terms are used interchangeably in describing outpatient service contracts?
Answer:
Encounter and Visit

Question:
2. Coding guideline for inconclusive diagnosis (probable, suspected, rule out, etc) .....
Answer:
do not apply to outpatients

Question:
3. In the outpatient setting what term is used in lieu of the principal diagnosis?
Answer:
The first listed diagnosis

Question:
4. How many visits does it take to confirm a diagnosis
Answer:
It may take two or more visits before the diagnosis is confirmed

Question:
5. When a patient presents for outpatient surgery what should be coded as the first-listed diagnosis?
Answer:
The reason for the surgery should be coded as the first-listed diagnosis *** even if the surgery is not
performed due to a contraindication.***

Question:
6. When a patient is admitted for observation for a medical condition what should be coded as the
first-listed diagnosis?
Answer:
Assign a code for the medical condition as the first-listed diagnosis.

Question:
7. How should it be coded if a patient presents for outpatient surgery and develops a complication
requiring admission to observation.
Answer:
The reason for the surgery will be the 1st reported diagnosis and Codes for the complications will be the
secondary diagnoses

Question:
8. When are codes that describe signs and symptoms acceptable for reporting purposes?

, Answer:
When a diagnosis has not been established by the provider.

Question:
9. ICD-10-CM is composed of codes with how many characters?
Answer:
3,4,5,6, or 7 characters.

Question:
10. Codes with 3 characters are included in ICD-10-CM as what?
Answer:
The heading of a category of codes that may be further subdivided by the use of 4th, 5th, 6th, or 7th
characters to provide greater specification.

Question:
11. List first the ICD-10-CM code for the diagnosis, condition, problem, or other reason for encounter/visit
known to be ........................
Answer:
Chiefly responsible for the service provided

Question:
12. Instead of coding "probable", Suspected", "questionable", etc. what should be coded?
Answer:
Code the condition to the highest degree of certainty for that encounter/visit, such as symptoms, signs,
abnormal test results, or other reason for the visit.

Question:
13. How many times can chronic diseases treated on an ongoing basis be coded and reported?
Answer:
Chronic diseases treated on an ongoing basis may be coded and reported as many times as the patient
receives treatment and care for the condition.

Question:
14. Info: Code all documented conditions that coexist at the time of the encounter/visit and require or
affect patient care, treatment, or management.
Answer:
Info: Do not code conditions that were previously treated and no longer exist **Unless it is a history code
that might have an impact on the current care or influence treatment

Question:
15. What code should be sequenced first for patients receiving diagnostic services only during an
encounter/visit?
What else can be coded?
Answer:
Sequence first the diagnosis, condition, problems, or other reason for encounter/visit shown in the medical
record to be chiefly responsible for the outpatient services provided during the encounter/visit.
Codes for other diagnoses (chronic conditions) may be sequenced as additional diagnoses.