D521-INTRODUCTION TO MEDICAL CODING
QUESTIONS AND ANSWERS 2025
Diagnosis - CORRECT ANSWER- identification of a disease by a licensed provider
Morbidity - CORRECT ANSWER- Refers to ill health in an individual and the levels of ill
health in a population or group.
Mortality - CORRECT ANSWER- the state of being subject to death
Comorbidity - CORRECT ANSWER- a secondary condition that is present on admission
and causes an increase in length of stay (LOS)
Complication - CORRECT ANSWER- a secondary condition that arises during
hospitalization and causes an increase in length of stay (LOS)
Principal diagnosis - CORRECT ANSWER- that condition established after study, which
is found to be primarily responsible for admission of the patient to the hospital
What is a characteristic of ICD-6? - CORRECT ANSWER- The first version of ICD used
for both death classification and disease indexing
What was the first ICD revision for which an alternate was made due to disagreements?
- CORRECT ANSWER- The United States developed its own version of ICD-8 based
on disagreements over the circulatory section.
Which characteristic of ICD-10-PCS represents a difference from ICD-9-CM? -
CORRECT ANSWER- No diagnostic information is included.
American Health Information Management Association (AHIMA) - CORRECT
ANSWER- a professional organization for health information management (HIM)
professionals
American Hospital Association (AHA) - CORRECT ANSWER- Non profit group or
alliance of member hospitals and health care organizations that promote the interests of
hospitals. It is an advocacy group for health care organizations, particularly hospitals
World Health Organization (WHO) - CORRECT ANSWER- A group within the United
Nations responsible for human health, including combating the spread of infectious
diseases and health issues related to natural disasters.
, History of Present Illness (HPI) - CORRECT ANSWER- eight categories that constitute
a chronological description of an illness.
History of Present Illness (HPI) eight categories - CORRECT ANSWER- How long have
you had the sore throat? (duration)
What part of your throat hurts? (location)
Is the pain continuous? Does it become better or worse? (timing)
How does it compare to other sore throats you have had? (severity)
Do you also have other symptoms? (associated signs and symptoms)
What are you doing when it hurts? (context)
How would you describe the pain? (quality)
What have you done to obtain relief? Did it work? (modifying factors)
Common Diagnosis coding process errors - CORRECT ANSWER- Illegible physician
handwriting
Illogical physician diagnosis documentation
Lack of physician documentation
Transcription errors by typist or voice-recognition systems
Content of the rest of the patient's medical record does not support the diagnosis
documented
Lack of specificity
Hybrid Record - CORRECT ANSWER- A combination of paper and electronic records;
a health record that includes both paper and electronic elements
QUESTIONS AND ANSWERS 2025
Diagnosis - CORRECT ANSWER- identification of a disease by a licensed provider
Morbidity - CORRECT ANSWER- Refers to ill health in an individual and the levels of ill
health in a population or group.
Mortality - CORRECT ANSWER- the state of being subject to death
Comorbidity - CORRECT ANSWER- a secondary condition that is present on admission
and causes an increase in length of stay (LOS)
Complication - CORRECT ANSWER- a secondary condition that arises during
hospitalization and causes an increase in length of stay (LOS)
Principal diagnosis - CORRECT ANSWER- that condition established after study, which
is found to be primarily responsible for admission of the patient to the hospital
What is a characteristic of ICD-6? - CORRECT ANSWER- The first version of ICD used
for both death classification and disease indexing
What was the first ICD revision for which an alternate was made due to disagreements?
- CORRECT ANSWER- The United States developed its own version of ICD-8 based
on disagreements over the circulatory section.
Which characteristic of ICD-10-PCS represents a difference from ICD-9-CM? -
CORRECT ANSWER- No diagnostic information is included.
American Health Information Management Association (AHIMA) - CORRECT
ANSWER- a professional organization for health information management (HIM)
professionals
American Hospital Association (AHA) - CORRECT ANSWER- Non profit group or
alliance of member hospitals and health care organizations that promote the interests of
hospitals. It is an advocacy group for health care organizations, particularly hospitals
World Health Organization (WHO) - CORRECT ANSWER- A group within the United
Nations responsible for human health, including combating the spread of infectious
diseases and health issues related to natural disasters.
, History of Present Illness (HPI) - CORRECT ANSWER- eight categories that constitute
a chronological description of an illness.
History of Present Illness (HPI) eight categories - CORRECT ANSWER- How long have
you had the sore throat? (duration)
What part of your throat hurts? (location)
Is the pain continuous? Does it become better or worse? (timing)
How does it compare to other sore throats you have had? (severity)
Do you also have other symptoms? (associated signs and symptoms)
What are you doing when it hurts? (context)
How would you describe the pain? (quality)
What have you done to obtain relief? Did it work? (modifying factors)
Common Diagnosis coding process errors - CORRECT ANSWER- Illegible physician
handwriting
Illogical physician diagnosis documentation
Lack of physician documentation
Transcription errors by typist or voice-recognition systems
Content of the rest of the patient's medical record does not support the diagnosis
documented
Lack of specificity
Hybrid Record - CORRECT ANSWER- A combination of paper and electronic records;
a health record that includes both paper and electronic elements
