, Solution manual for 3 3-2-1 Code It! 2024
Edition, 12th Edition Michelle A. Green
Notes
1- All Chapters are step by step.
2- We have shown you 10 pages.
3- The file contains all Appendix and Excel
sheet if it exists.
4- We have all what you need, we make
update at every time. There are many
new editions waiting you.
5- If you think you purchased the wrong file
You can contact us at every time, we can
replace it with true one.
Our email:
Our website:
testbanks-store.com
, Solution and Answer Guide: Green, 3-2-1 Code It! 2024, 9780357932209; Chapter 1: Overview of Coding
Solution and Answer Guide
GREEN, 3-2-1 CODE IT! 2024, 9780357932209; CHAPTER 1: OVERVIEW OF CODING
TABLE OF CONTENTS
Exercises......................................................................................................................................1
Exercise 1.1: Career as a Coder ............................................................................................... 1
Exercise 1.2: Professional Associations....................................................................................2
Exercise 1.3: Coding Systems and Processes..........................................................................3
Exercise 1.4: Other Classification Systems and Databases......................................................4
Exercise 1.5: Documentation as Basis for Coding.....................................................................6
Exercise 1.6: Health Data Collection ......................................................................................... 8
Review..........................................................................................................................................9
Multiple Choice .......................................................................................................................... 9
EXERCISES
EXERCISE 1.1: CAREER AS A CODER
1. A coder is required to have a working knowledge of the CPT, HCPCS Level II, ICD-10-CM, and ___
_______ coding systems.
Answer: ICD-10-PCS
Analysis: A coder is required to have a working knowledge of the CPT, HCPCS Level II, ICD-10-
CM, and ICD-10-PCS coding systems.
2. The complexity and intensity of procedures performed and services provided during an outpatient
or physician office encounter are captured as part of __________ coding.
Answer: professional
Analysis: The complexity and intensity of procedures performed and services provided during an
outpatient or physician office encounter are captured as part of professional coding.
3. The intensity of services and severity of illness associated with inpatient care are captured as part
of __________ (or facility) coding.
Answer: institutional
Analysis: The intensity of services and severity of illness associated with inpatient care are captur
ed as part of institutional (or facility) coding.
© 2025 Cengage Learning, Inc. All Rights Reserved. May not be scanned, copied or duplicated, or posted to a publicly 1
accessible website, in whole or in part.
, Solution and Answer Guide: Green, 3-2-1 Code It! 2024, 9780357932209; Chapter 1: Overview of Coding
4. When a multi-hospital system provides physician office services along with traditional inpatient, o
utpatient, and emergency department hospital care, the concept of __________ coding is adopte
d to facilitate professional and institutional billing.
Answer: single-path
Analysis: When a multi-hospital system provides physician office services along with traditional in
patient, outpatient, and emergency department hospital care, the concept of single-path coding is
adopted to facilitate professional and institutional billing.
5. A profession that is closely related to that of a coder is a health __________ specialist (or claims
examiner) who reviews health-related claims to determine whether the costs are reasonable and
medically necessary based on the patient’s diagnosis reported for procedures performed and ser
vices provided.
Answer: insurance
Analysis: A profession that is closely related to that of a coder is a health insurance specialist (or
claims examiner) who reviews health-related claims to determine whether the costs are reasonabl
e and medically necessary based on the patient’s diagnosis reported for procedures performed a
nd services provided.
EXERCISE 1.2: PROFESSIONAL ASSOCIATIONS
1. Students who become members of __________ association(s) usually pay a reduced membershi
p fee and receive most of the same benefits as active members.
Answer: professional
Analysis: Students who become members of professional association(s) usually pay a reduced m
embership fee and receive most of the same benefits as active members.
2. Attending professional association conferences and meetings provides opportunities to ________
__ (or interact) with other professionals, which can facilitate being placed for internship or job plac
ement.
Answer: network
Analysis: Attending professional association conferences and meetings provides opportunities to
network (or interact) with other professionals, which can facilitate being placed for internship or jo
b placement.
3. A medical assistant usually joins the American Medical Technologists (AMT) or the __________.
Answer: American Association of Medical Assistants (AAMA)
Analysis: A medical assistant usually joins the American Medical Technologists (AMT) or the Ame
rican Association of Medical Assistants (AAMA).
4. An Internet-based discussion forum that covers a variety of professional topics and issues is calle
d an online discussion board or __________.
Answer: listserv
Analysis: An Internet-based discussion forum that covers a variety of professional topics and issu
es is called an online discussion board or listserv.
© 2025 Cengage Learning, Inc. All Rights Reserved. May not be scanned, copied or duplicated, or posted to a publicly 2
accessible website, in whole or in part.
, Solution and Answer Guide: Green, 3-2-1 Code It! 2024, 9780357932209; Chapter 1: Overview of Coding
5. A coder usually joins either the American Health Information Management Association (AHIMA) o
r the __________.
Answer: AAPC
Analysis: A coder usually joins either the American Health Information Management Association (
AHIMA) or the AAPC.
EXERCISE 1.3: CODING SYSTEMS AND PROCESSES
1. A medical nomenclature that is organized according to similar conditions, diseases, procedures, a
nd services, and contains codes for each is called a __________ (or classification) system.
Answer: coding
Analysis: A medical nomenclature that is organized according to similar conditions, diseases, pro
cedures, and services, and contains codes for each is called a coding (or classification) system.
2. All diseases, injuries, and reasons for an encounter, whether patients are treated as inpatients or
outpatients, are coded using the __________ classification system.
Answer: ICD-10-CM
Analysis: All diseases, injuries, and reasons for an encounter, whether patients are treated as inp
atients or outpatients, are coded using the ICD-10-CM classification system.
3. Inpatient hospital procedures and services are coded using the __________ classification syste
m.
Answer: ICD-10-PCS
Analysis: Inpatient hospital procedures and services are coded using the ICD-10-PCS classificati
on system.
4. A public or private entity that processes or facilitates the processing of health information and clai
ms from a nonstandard to a standard format is called a health care __________.
Answer: clearinghouse
Analysis: A public or private entity that processes or facilitates the processing of health informatio
n and claims from a nonstandard to a standard format is called a health care clearinghouse.
5. Routinely assigning lower-level CPT codes for convenience instead of reviewing patient record do
cumentation and the coding manual to determine the proper code to be reported is called ______
____.
Answer: downcoding
Analysis: Routinely assigning lower-level CPT codes as a convenience instead of reviewing patie
nt record documentation and the coding manual to determine the proper code to be reported is ca
lled downcoding.
6. Reporting codes that are not supported by documentation in the patient record for the purpose of
increasing reimbursement is called __________.
Answer: upcoding
© 2025 Cengage Learning, Inc. All Rights Reserved. May not be scanned, copied or duplicated, or posted to a publicly 3
accessible website, in whole or in part.
, Solution and Answer Guide: Green, 3-2-1 Code It! 2024, 9780357932209; Chapter 1: Overview of Coding
Analysis: Reporting codes that are not supported by documentation in the patient record for the p
urpose of increasing reimbursement is called upcoding.
7. Reporting codes for signs and symptoms in addition to the established diagnosis code is called _
_________.
Answer: overcoding
Analysis: Reporting codes for signs and symptoms in addition to the established diagnosis code i
s called overcoding.
8. Reporting multiple codes to increase reimbursement when a single combination code should be r
eported is called __________.
Answer: unbundling
Analysis: Reporting multiple codes to increase reimbursement when a single combination code s
hould be reported is called unbundling.
9. Coders should always avoid assumption coding, and can do so by generating a physician _______
___ when documentation needs clarification prior to the assignment of codes.
Answer: query
Analysis: Coders should always avoid assumption coding, and can do so by generating a physician q
uery when documentation needs clarification prior to the assignment of codes.
10. Software that automatically generates medical codes by analyzing clinical documentation in the el
ectronic health record or electronic medical record is called __________.
Answer: computer-assisted coding (CAC)
Analysis: Software that automatically generates medical codes by analyzing clinical documentation i
n the electronic health record or electronic medical record is called computer-assisted coding (CA
C).
EXERCISE 1.4: OTHER CLASSIFICATION SYSTEMS AND DATABASES
1. The classification of neoplasms used by cancer registries throughout the world to record
incidence of malignancy and survival rates is called the __________.
Answer: International Classification of Diseases for Oncology, Third Edition (ICD-O-3)
Analysis: The classification of neoplasms used by cancer registries throughout the world to record
incidence of malignancy and survival rates is called the ICD-O-3. (The capital letter O in the
classification system’s abbreviation refers to Oncology.)
© 2025 Cengage Learning, Inc. All Rights Reserved. May not be scanned, copied or duplicated, or posted to a publicly 4
accessible website, in whole or in part.
, Solution and Answer Guide: Green, 3-2-1 Code It! 2024, 9780357932209; Chapter 1: Overview of Coding
2. Specific sets of patient characteristics (or case-mix groups) on which payment determinations are
made under several prospective payment systems are represented by the __________.
Answer: Health Insurance Prospective Payment System (HIPPS)
Analysis: Specific sets of patient characteristics (or case-mix groups) on which payment
determinations are made under several prospective payment systems are represented by the
Health Insurance Prospective Payment System (HIPPS).
3. The set of files and software that allows many health and biomedical vocabularies and standards
to enable interoperability among computer systems is called the __________.
Answer: Unified Medical Language System (UMLS)
Analysis: The set of files and software that allows many health and biomedical vocabularies and
standards to enable interoperability among computer systems is called the Unified Medical
Language System (UMLS).
4. The coding system that is used to classify dental procedures and services is called the
__________.
Answer: Current Dental Terminology (CDT)
Analysis: The coding system that is used to classify dental procedures and services is called the
Current Dental Terminology (CDT).
5. The system that classifies health and health-related domains to describe body functions and
structures, activities, and participation is called the __________.
Answer: International Classification of Functioning, Disability and Health (ICF)
Analysis: The system that classifies health and health-related domains to describe body functions
and structures, activities, and participation is called the International Classification of Functioning,
Disability and Health (ICF).
6. The system that classifies services not included in the CPT manual to describe the service,
supply, or therapy provided and may also be assigned to report nursing services and alternative
medicine procedures is called __________.
Answer: Alternative Billing Codes (ABC codes)
Analysis: The system that classifies services not included in the CPT manual to describe the
service, supply, or therapy provided and may also be assigned to report nursing services and
alternative medicine procedures is called Alternative Billing Codes (ABC codes).
7. The nomenclature that provides normalized names for clinical drugs and links its names to many
of the drug vocabularies commonly used in pharmacy management and drug interaction software
is called __________.
Answer: RxNorm
Analysis: The nomenclature that provides normalized names for clinical drugs and links its names
to many of the drug vocabularies commonly used in pharmacy management and drug interaction
software is called RxNorm.
© 2025 Cengage Learning, Inc. All Rights Reserved. May not be scanned, copied or duplicated, or posted to a publicly 5
accessible website, in whole or in part.
, Solution and Answer Guide: Green, 3-2-1 Code It! 2024, 9780357932209; Chapter 1: Overview of Coding
8. An electronic database and universal standard that is used to identify medical laboratory
observations and for the purpose of clinical care and management is called the __________.
Answer: Logical Observation Identifiers Names and Codes (LOINC)
Analysis: An electronic database and universal standard that is used to identify medical
laboratory observations and for the purpose of clinical care and management is called the Logical
Observation Identifiers Names and Codes (LOINC).
9. The American Psychiatric Association published a standard classification of mental disorders call
ed the __________-5.
Answer: DSM
Analysis: The American Psychiatric Association published a standard classification of mental diso
rders called the DSM-5. DSM means Diagnostic and Statistical Manual of Mental Disorders, and -
5 refers to the fifth edition.
10. The system that provides a new standardized framework and a unique coding structure for
assessing, documenting, and classifying home health and ambulatory care is called the
__________ System.
Answer: Clinical Care Classification (CCC)
Analysis: The system that provides a new standardized framework and a unique coding structure
for assessing, documenting, and classifying home health and ambulatory care is called the Clinic
al Care Classification (CCC) System.
EXERCISE 1.5: DOCUMENTATION AS BASIS FOR CODING
1. Continuity of patient care is considered a __________ purpose of the patient record.
a. primary
b. secondary
Answer: a
Analysis:
a. Correct. Continuity of patient care is considered a primary purpose of the patient, and it i
nvolves documenting patient care procedures and services so that others who treat the p
atient have a source of information upon which to base additional care and treatment.
b. Incorrect. Secondary purposes of the record include evaluating the quality of patient care;
providing data for use in clinical research, epidemiology studies, education, public policy
making, facilities planning, and health care statistics; providing information to third-party p
ayers for reimbursement; and serving the medicolegal interests of the patient, facility, and
providers of care. Continuity of patient care is a primary purpose of the patient, and it invo
lves documenting patient care procedures and services so that others who treat the patie
nt have a source of information upon which to base additional care and treatment.
© 2025 Cengage Learning, Inc. All Rights Reserved. May not be scanned, copied or duplicated, or posted to a publicly 6
accessible website, in whole or in part.
, Solution and Answer Guide: Green, 3-2-1 Code It! 2024, 9780357932209; Chapter 1: Overview of Coding
2. Evaluating quality of patient care is considered a __________ purpose of the patient record.
a. primary
b. secondary
Answer: b
Analysis:
a. Incorrect. The primary purpose of the patient record is to provide for continuity of care, w
hich involves documenting patient care services so that others who treat the patient have
a source of information on which to base additional care and treatment. Evaluating the qu
ality of patient care is considered a secondary purpose of the patient record. Secondary p
urposes of the record include evaluating the quality of patient care; providing data for use
in clinical research, epidemiology studies, education, public policy making, facilities planni
ng, and health care statistics; providing information to third-party payers for reimburseme
nt; and serving the medicolegal interests of the patient, facility, and providers of care.
b. Correct. Evaluating the quality of patient care is considered a secondary purpose of the
patient record. Secondary purposes of the record include evaluating the quality of patient
care; providing data for use in clinical research, epidemiology studies, education, public p
olicy making, facilities planning, and health care statistics; providing information to third-p
arty payers for reimbursement; and serving the medicolegal interests of the patient, facilit
y, and providers of care.
3. Which is an example of patient demographic data?
a. date of birth
b. discharge diagnosis
Answer: a
Analysis:
a. Correct. The date of birth is an example of patient demographic data. Demographic data
are patient identification information that is collected according to facility policy.
b. Incorrect. The discharge diagnosis is an example of patient clinical data. The date of birth
is an example of patient demographic data. Demographic data are patient identification in
formation that is collected according to facility policy.
4. Medical necessity requires providers to document procedures, services, and supplies that are pro
per and needed for the
a. convenience of the physician or health care facility.
b. diagnosis or treatment of a patient’s medical condition.
Answer: b
Analysis:
a. Incorrect. Performing procedures, services, and supplies for the convenience of the physi
cian or health care facility is not permitted. Medical necessity requires providers to docum
ent procedures, services, and supplies that are proper and needed for the diagnosis or tr
eatment of a patient’s medical condition.
b. Correct. Medical necessity requires providers to document procedures, services, and su
pplies that are proper and needed for the diagnosis or treatment of a patient’s medical co
ndition.
5. Which is the business record for a patient encounter because it documents health care services p
rovided?
© 2025 Cengage Learning, Inc. All Rights Reserved. May not be scanned, copied or duplicated, or posted to a publicly 7
accessible website, in whole or in part.
, Solution and Answer Guide: Green, 3-2-1 Code It! 2024, 9780357932209; Chapter 1: Overview of Coding
a. demographic data collected on admission
b. patient record housed in the facility
Answer: b
Analysis:
a. Incorrect. Demographic data collected on admission is included on the face sheet of the
manual patient record or in the electronic health record; however, it is not the business re
cord for a patient record because it does not document health care services provided. Th
e patient record housed in the facility is the business record for a patient encounter becau
se it documents health care services provided.
b. Correct. The patient record housed in the facility is the business record for a patient enco
unter because it documents health care services provided.
EXERCISE 1.6: HEALTH DATA COLLECTION
1. Appointment scheduling and claims processing are processes associated with medical
__________ software.
Answer: management
Analysis: Appointment scheduling and claims processing are processes associated with medical
management software, which is a combination of practice management and medical billing
software that automates the daily workflow and procedures of a physician’s office or clinic. The
software automates appointment scheduling, claims processing, patient invoicing, patient
management, and generating reports.
2. Hospital coders and abstractors use automated case __________ software to collect and report
inpatient and outpatient data for statistical analysis and reimbursement purposes.
Answer: abstracting
Analysis: Hospitals (and other health care facility) coders and abstractors use automated case
abstracting software to collect and report inpatient and outpatient data for statistical analysis and
reimbursement purposes. Data is entered into an abstracting software program, and the facility’s
billing department imports it to the UB-04 claim for submission to third-party payers.
3. Physicians’ offices submit data to third-party payers on the __________ claim.
Answer: CMS-1500
Analysis: Physicians’ offices submit data to third-party payers on the CMS-1500 claim, which is
the standard claim submitted by physicians to third-party payers for office encounters and
professional services (e.g., provided to hospital inpatients). Physician offices use medical
management software to enter claims data for electronic submission to third-party payers or
clearinghouses. Some eligible medical practices continue to print paper-based CMS-1500 claims,
and are mailed or faxed to clearinghouses or third-party payers for processing.
4. Hospitals submit data to third-party payers on the __________ (or CMS-1450) claim.
Answer: UB-04
Analysis: Hospitals submit data to third-party payers on the UB-04 (or CMS-1450) claim, which is
the standard claim submitted by health care institutions to third-party payers for inpatient and
outpatient services. (UB means “uniform bill.”)
© 2025 Cengage Learning, Inc. All Rights Reserved. May not be scanned, copied or duplicated, or posted to a publicly 8
accessible website, in whole or in part.
Edition, 12th Edition Michelle A. Green
Notes
1- All Chapters are step by step.
2- We have shown you 10 pages.
3- The file contains all Appendix and Excel
sheet if it exists.
4- We have all what you need, we make
update at every time. There are many
new editions waiting you.
5- If you think you purchased the wrong file
You can contact us at every time, we can
replace it with true one.
Our email:
Our website:
testbanks-store.com
, Solution and Answer Guide: Green, 3-2-1 Code It! 2024, 9780357932209; Chapter 1: Overview of Coding
Solution and Answer Guide
GREEN, 3-2-1 CODE IT! 2024, 9780357932209; CHAPTER 1: OVERVIEW OF CODING
TABLE OF CONTENTS
Exercises......................................................................................................................................1
Exercise 1.1: Career as a Coder ............................................................................................... 1
Exercise 1.2: Professional Associations....................................................................................2
Exercise 1.3: Coding Systems and Processes..........................................................................3
Exercise 1.4: Other Classification Systems and Databases......................................................4
Exercise 1.5: Documentation as Basis for Coding.....................................................................6
Exercise 1.6: Health Data Collection ......................................................................................... 8
Review..........................................................................................................................................9
Multiple Choice .......................................................................................................................... 9
EXERCISES
EXERCISE 1.1: CAREER AS A CODER
1. A coder is required to have a working knowledge of the CPT, HCPCS Level II, ICD-10-CM, and ___
_______ coding systems.
Answer: ICD-10-PCS
Analysis: A coder is required to have a working knowledge of the CPT, HCPCS Level II, ICD-10-
CM, and ICD-10-PCS coding systems.
2. The complexity and intensity of procedures performed and services provided during an outpatient
or physician office encounter are captured as part of __________ coding.
Answer: professional
Analysis: The complexity and intensity of procedures performed and services provided during an
outpatient or physician office encounter are captured as part of professional coding.
3. The intensity of services and severity of illness associated with inpatient care are captured as part
of __________ (or facility) coding.
Answer: institutional
Analysis: The intensity of services and severity of illness associated with inpatient care are captur
ed as part of institutional (or facility) coding.
© 2025 Cengage Learning, Inc. All Rights Reserved. May not be scanned, copied or duplicated, or posted to a publicly 1
accessible website, in whole or in part.
, Solution and Answer Guide: Green, 3-2-1 Code It! 2024, 9780357932209; Chapter 1: Overview of Coding
4. When a multi-hospital system provides physician office services along with traditional inpatient, o
utpatient, and emergency department hospital care, the concept of __________ coding is adopte
d to facilitate professional and institutional billing.
Answer: single-path
Analysis: When a multi-hospital system provides physician office services along with traditional in
patient, outpatient, and emergency department hospital care, the concept of single-path coding is
adopted to facilitate professional and institutional billing.
5. A profession that is closely related to that of a coder is a health __________ specialist (or claims
examiner) who reviews health-related claims to determine whether the costs are reasonable and
medically necessary based on the patient’s diagnosis reported for procedures performed and ser
vices provided.
Answer: insurance
Analysis: A profession that is closely related to that of a coder is a health insurance specialist (or
claims examiner) who reviews health-related claims to determine whether the costs are reasonabl
e and medically necessary based on the patient’s diagnosis reported for procedures performed a
nd services provided.
EXERCISE 1.2: PROFESSIONAL ASSOCIATIONS
1. Students who become members of __________ association(s) usually pay a reduced membershi
p fee and receive most of the same benefits as active members.
Answer: professional
Analysis: Students who become members of professional association(s) usually pay a reduced m
embership fee and receive most of the same benefits as active members.
2. Attending professional association conferences and meetings provides opportunities to ________
__ (or interact) with other professionals, which can facilitate being placed for internship or job plac
ement.
Answer: network
Analysis: Attending professional association conferences and meetings provides opportunities to
network (or interact) with other professionals, which can facilitate being placed for internship or jo
b placement.
3. A medical assistant usually joins the American Medical Technologists (AMT) or the __________.
Answer: American Association of Medical Assistants (AAMA)
Analysis: A medical assistant usually joins the American Medical Technologists (AMT) or the Ame
rican Association of Medical Assistants (AAMA).
4. An Internet-based discussion forum that covers a variety of professional topics and issues is calle
d an online discussion board or __________.
Answer: listserv
Analysis: An Internet-based discussion forum that covers a variety of professional topics and issu
es is called an online discussion board or listserv.
© 2025 Cengage Learning, Inc. All Rights Reserved. May not be scanned, copied or duplicated, or posted to a publicly 2
accessible website, in whole or in part.
, Solution and Answer Guide: Green, 3-2-1 Code It! 2024, 9780357932209; Chapter 1: Overview of Coding
5. A coder usually joins either the American Health Information Management Association (AHIMA) o
r the __________.
Answer: AAPC
Analysis: A coder usually joins either the American Health Information Management Association (
AHIMA) or the AAPC.
EXERCISE 1.3: CODING SYSTEMS AND PROCESSES
1. A medical nomenclature that is organized according to similar conditions, diseases, procedures, a
nd services, and contains codes for each is called a __________ (or classification) system.
Answer: coding
Analysis: A medical nomenclature that is organized according to similar conditions, diseases, pro
cedures, and services, and contains codes for each is called a coding (or classification) system.
2. All diseases, injuries, and reasons for an encounter, whether patients are treated as inpatients or
outpatients, are coded using the __________ classification system.
Answer: ICD-10-CM
Analysis: All diseases, injuries, and reasons for an encounter, whether patients are treated as inp
atients or outpatients, are coded using the ICD-10-CM classification system.
3. Inpatient hospital procedures and services are coded using the __________ classification syste
m.
Answer: ICD-10-PCS
Analysis: Inpatient hospital procedures and services are coded using the ICD-10-PCS classificati
on system.
4. A public or private entity that processes or facilitates the processing of health information and clai
ms from a nonstandard to a standard format is called a health care __________.
Answer: clearinghouse
Analysis: A public or private entity that processes or facilitates the processing of health informatio
n and claims from a nonstandard to a standard format is called a health care clearinghouse.
5. Routinely assigning lower-level CPT codes for convenience instead of reviewing patient record do
cumentation and the coding manual to determine the proper code to be reported is called ______
____.
Answer: downcoding
Analysis: Routinely assigning lower-level CPT codes as a convenience instead of reviewing patie
nt record documentation and the coding manual to determine the proper code to be reported is ca
lled downcoding.
6. Reporting codes that are not supported by documentation in the patient record for the purpose of
increasing reimbursement is called __________.
Answer: upcoding
© 2025 Cengage Learning, Inc. All Rights Reserved. May not be scanned, copied or duplicated, or posted to a publicly 3
accessible website, in whole or in part.
, Solution and Answer Guide: Green, 3-2-1 Code It! 2024, 9780357932209; Chapter 1: Overview of Coding
Analysis: Reporting codes that are not supported by documentation in the patient record for the p
urpose of increasing reimbursement is called upcoding.
7. Reporting codes for signs and symptoms in addition to the established diagnosis code is called _
_________.
Answer: overcoding
Analysis: Reporting codes for signs and symptoms in addition to the established diagnosis code i
s called overcoding.
8. Reporting multiple codes to increase reimbursement when a single combination code should be r
eported is called __________.
Answer: unbundling
Analysis: Reporting multiple codes to increase reimbursement when a single combination code s
hould be reported is called unbundling.
9. Coders should always avoid assumption coding, and can do so by generating a physician _______
___ when documentation needs clarification prior to the assignment of codes.
Answer: query
Analysis: Coders should always avoid assumption coding, and can do so by generating a physician q
uery when documentation needs clarification prior to the assignment of codes.
10. Software that automatically generates medical codes by analyzing clinical documentation in the el
ectronic health record or electronic medical record is called __________.
Answer: computer-assisted coding (CAC)
Analysis: Software that automatically generates medical codes by analyzing clinical documentation i
n the electronic health record or electronic medical record is called computer-assisted coding (CA
C).
EXERCISE 1.4: OTHER CLASSIFICATION SYSTEMS AND DATABASES
1. The classification of neoplasms used by cancer registries throughout the world to record
incidence of malignancy and survival rates is called the __________.
Answer: International Classification of Diseases for Oncology, Third Edition (ICD-O-3)
Analysis: The classification of neoplasms used by cancer registries throughout the world to record
incidence of malignancy and survival rates is called the ICD-O-3. (The capital letter O in the
classification system’s abbreviation refers to Oncology.)
© 2025 Cengage Learning, Inc. All Rights Reserved. May not be scanned, copied or duplicated, or posted to a publicly 4
accessible website, in whole or in part.
, Solution and Answer Guide: Green, 3-2-1 Code It! 2024, 9780357932209; Chapter 1: Overview of Coding
2. Specific sets of patient characteristics (or case-mix groups) on which payment determinations are
made under several prospective payment systems are represented by the __________.
Answer: Health Insurance Prospective Payment System (HIPPS)
Analysis: Specific sets of patient characteristics (or case-mix groups) on which payment
determinations are made under several prospective payment systems are represented by the
Health Insurance Prospective Payment System (HIPPS).
3. The set of files and software that allows many health and biomedical vocabularies and standards
to enable interoperability among computer systems is called the __________.
Answer: Unified Medical Language System (UMLS)
Analysis: The set of files and software that allows many health and biomedical vocabularies and
standards to enable interoperability among computer systems is called the Unified Medical
Language System (UMLS).
4. The coding system that is used to classify dental procedures and services is called the
__________.
Answer: Current Dental Terminology (CDT)
Analysis: The coding system that is used to classify dental procedures and services is called the
Current Dental Terminology (CDT).
5. The system that classifies health and health-related domains to describe body functions and
structures, activities, and participation is called the __________.
Answer: International Classification of Functioning, Disability and Health (ICF)
Analysis: The system that classifies health and health-related domains to describe body functions
and structures, activities, and participation is called the International Classification of Functioning,
Disability and Health (ICF).
6. The system that classifies services not included in the CPT manual to describe the service,
supply, or therapy provided and may also be assigned to report nursing services and alternative
medicine procedures is called __________.
Answer: Alternative Billing Codes (ABC codes)
Analysis: The system that classifies services not included in the CPT manual to describe the
service, supply, or therapy provided and may also be assigned to report nursing services and
alternative medicine procedures is called Alternative Billing Codes (ABC codes).
7. The nomenclature that provides normalized names for clinical drugs and links its names to many
of the drug vocabularies commonly used in pharmacy management and drug interaction software
is called __________.
Answer: RxNorm
Analysis: The nomenclature that provides normalized names for clinical drugs and links its names
to many of the drug vocabularies commonly used in pharmacy management and drug interaction
software is called RxNorm.
© 2025 Cengage Learning, Inc. All Rights Reserved. May not be scanned, copied or duplicated, or posted to a publicly 5
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, Solution and Answer Guide: Green, 3-2-1 Code It! 2024, 9780357932209; Chapter 1: Overview of Coding
8. An electronic database and universal standard that is used to identify medical laboratory
observations and for the purpose of clinical care and management is called the __________.
Answer: Logical Observation Identifiers Names and Codes (LOINC)
Analysis: An electronic database and universal standard that is used to identify medical
laboratory observations and for the purpose of clinical care and management is called the Logical
Observation Identifiers Names and Codes (LOINC).
9. The American Psychiatric Association published a standard classification of mental disorders call
ed the __________-5.
Answer: DSM
Analysis: The American Psychiatric Association published a standard classification of mental diso
rders called the DSM-5. DSM means Diagnostic and Statistical Manual of Mental Disorders, and -
5 refers to the fifth edition.
10. The system that provides a new standardized framework and a unique coding structure for
assessing, documenting, and classifying home health and ambulatory care is called the
__________ System.
Answer: Clinical Care Classification (CCC)
Analysis: The system that provides a new standardized framework and a unique coding structure
for assessing, documenting, and classifying home health and ambulatory care is called the Clinic
al Care Classification (CCC) System.
EXERCISE 1.5: DOCUMENTATION AS BASIS FOR CODING
1. Continuity of patient care is considered a __________ purpose of the patient record.
a. primary
b. secondary
Answer: a
Analysis:
a. Correct. Continuity of patient care is considered a primary purpose of the patient, and it i
nvolves documenting patient care procedures and services so that others who treat the p
atient have a source of information upon which to base additional care and treatment.
b. Incorrect. Secondary purposes of the record include evaluating the quality of patient care;
providing data for use in clinical research, epidemiology studies, education, public policy
making, facilities planning, and health care statistics; providing information to third-party p
ayers for reimbursement; and serving the medicolegal interests of the patient, facility, and
providers of care. Continuity of patient care is a primary purpose of the patient, and it invo
lves documenting patient care procedures and services so that others who treat the patie
nt have a source of information upon which to base additional care and treatment.
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accessible website, in whole or in part.
, Solution and Answer Guide: Green, 3-2-1 Code It! 2024, 9780357932209; Chapter 1: Overview of Coding
2. Evaluating quality of patient care is considered a __________ purpose of the patient record.
a. primary
b. secondary
Answer: b
Analysis:
a. Incorrect. The primary purpose of the patient record is to provide for continuity of care, w
hich involves documenting patient care services so that others who treat the patient have
a source of information on which to base additional care and treatment. Evaluating the qu
ality of patient care is considered a secondary purpose of the patient record. Secondary p
urposes of the record include evaluating the quality of patient care; providing data for use
in clinical research, epidemiology studies, education, public policy making, facilities planni
ng, and health care statistics; providing information to third-party payers for reimburseme
nt; and serving the medicolegal interests of the patient, facility, and providers of care.
b. Correct. Evaluating the quality of patient care is considered a secondary purpose of the
patient record. Secondary purposes of the record include evaluating the quality of patient
care; providing data for use in clinical research, epidemiology studies, education, public p
olicy making, facilities planning, and health care statistics; providing information to third-p
arty payers for reimbursement; and serving the medicolegal interests of the patient, facilit
y, and providers of care.
3. Which is an example of patient demographic data?
a. date of birth
b. discharge diagnosis
Answer: a
Analysis:
a. Correct. The date of birth is an example of patient demographic data. Demographic data
are patient identification information that is collected according to facility policy.
b. Incorrect. The discharge diagnosis is an example of patient clinical data. The date of birth
is an example of patient demographic data. Demographic data are patient identification in
formation that is collected according to facility policy.
4. Medical necessity requires providers to document procedures, services, and supplies that are pro
per and needed for the
a. convenience of the physician or health care facility.
b. diagnosis or treatment of a patient’s medical condition.
Answer: b
Analysis:
a. Incorrect. Performing procedures, services, and supplies for the convenience of the physi
cian or health care facility is not permitted. Medical necessity requires providers to docum
ent procedures, services, and supplies that are proper and needed for the diagnosis or tr
eatment of a patient’s medical condition.
b. Correct. Medical necessity requires providers to document procedures, services, and su
pplies that are proper and needed for the diagnosis or treatment of a patient’s medical co
ndition.
5. Which is the business record for a patient encounter because it documents health care services p
rovided?
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accessible website, in whole or in part.
, Solution and Answer Guide: Green, 3-2-1 Code It! 2024, 9780357932209; Chapter 1: Overview of Coding
a. demographic data collected on admission
b. patient record housed in the facility
Answer: b
Analysis:
a. Incorrect. Demographic data collected on admission is included on the face sheet of the
manual patient record or in the electronic health record; however, it is not the business re
cord for a patient record because it does not document health care services provided. Th
e patient record housed in the facility is the business record for a patient encounter becau
se it documents health care services provided.
b. Correct. The patient record housed in the facility is the business record for a patient enco
unter because it documents health care services provided.
EXERCISE 1.6: HEALTH DATA COLLECTION
1. Appointment scheduling and claims processing are processes associated with medical
__________ software.
Answer: management
Analysis: Appointment scheduling and claims processing are processes associated with medical
management software, which is a combination of practice management and medical billing
software that automates the daily workflow and procedures of a physician’s office or clinic. The
software automates appointment scheduling, claims processing, patient invoicing, patient
management, and generating reports.
2. Hospital coders and abstractors use automated case __________ software to collect and report
inpatient and outpatient data for statistical analysis and reimbursement purposes.
Answer: abstracting
Analysis: Hospitals (and other health care facility) coders and abstractors use automated case
abstracting software to collect and report inpatient and outpatient data for statistical analysis and
reimbursement purposes. Data is entered into an abstracting software program, and the facility’s
billing department imports it to the UB-04 claim for submission to third-party payers.
3. Physicians’ offices submit data to third-party payers on the __________ claim.
Answer: CMS-1500
Analysis: Physicians’ offices submit data to third-party payers on the CMS-1500 claim, which is
the standard claim submitted by physicians to third-party payers for office encounters and
professional services (e.g., provided to hospital inpatients). Physician offices use medical
management software to enter claims data for electronic submission to third-party payers or
clearinghouses. Some eligible medical practices continue to print paper-based CMS-1500 claims,
and are mailed or faxed to clearinghouses or third-party payers for processing.
4. Hospitals submit data to third-party payers on the __________ (or CMS-1450) claim.
Answer: UB-04
Analysis: Hospitals submit data to third-party payers on the UB-04 (or CMS-1450) claim, which is
the standard claim submitted by health care institutions to third-party payers for inpatient and
outpatient services. (UB means “uniform bill.”)
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