CEMC EXAM WITH ALL CORRECT & 100% VERIFIED
ANSWERS|ACTUAL COMPLETE EXAM|ALREADY
GRADED A+ (JUST RELEASED)
__________________ are not a consideration when choosing the right answer. ✔Correct answer-
Individual payer rules
Follow the CPT coding guidelines unless... ✔Correct answer-It is specifically stated in the case note
or exam question that Medicare covers the patient.
Example of reporting additional signs and symptoms attributable to a definitive Dx ✔Correct
answer-The patient presents with shortness of breath. The next day, the MD determines the patient
has pneumonia ; but, feels that the shortness of breath may be due to a cardiac condition.
In such a case, you may still report the shortness of breath as a sign and symptom with the
pneumonia because the MD has documented reason to believe that the conditions are unrelated.
Do NOT ___________ or _____________ information ✔Correct answer-Extrapolate or assume
Select codes ONLY from what is apparent in the available documentation
The ___________ makes the determination as to whether a condition becomes chronic ✔Correct
answer-Doctor
Healthcare providers must begin using the most recent ICD-10-CM code revisions on ________ of
each year, with no ______. ✔Correct answer-October 1st
grace period to transition to the changes.
Coders will select an appropriate code for ______ or _________ (primary) versus _________
(secondary) based on the available documentation. ✔Correct answer-Acute
Sub-acute
Chronic
Example: A torn meniscus (S83. 2-) will become an internal derangement of knee (M23. -) after a
defined period.
If a patient's condition is acute/sub-acute and chronic, a single code does not describe the
combination. ✔Correct answer-The ICD-10-CM code book provides instruction that you would
report the acute (sub-acute) code as first-listed, with the chronic code secondary.
Multiple conditions reported with a single code ✔Correct answer-In some cases ICD-10-CM will
employ a single code to describe 2 or more conditions concurrently, such as primary Dx with an
associated 2ndary process (manifestation),
Or a primary Dx with an associated complication.
,The Official Guidelines note, ✔Correct answer-"A joint effort between the Healthcare provider and
the coder is essential to achieve complete and accurate documentation, code assignment, and
reporting of diagnoses and procedures."
Each ICD-10-CM code assigned must be ✔Correct answer-Supported by documentation linked to
that claim
** (individual dates of service must stand alone)
Coders must be mindful to not.... ✔Correct answer-Assume or extrapolate information from the
medical record
Example: Don't code a condition as acute when it is not documented as such.
Official Guidelines are divided into 4 sections ✔Correct answer-Section I: ICD-10-CM Conventions,
General Coding Guidelines, and
Chapter Specific Guidelines
Section II: Selection of Principal Dx.
Uniform Hospital Discharge Data Set
(UHDDS)
Section III: Rules for Additional Dx
Section IV: Dx Coding and Reporting Guidelines for Outpatient Services
Uniform Hospital Discharge Data Set ✔Correct answer-(UHDDS) : Defines the principle Dx as "that
condition established after study to be chiefly responsible for the admission of the patient to the
hospital for care."
Rules for Reporting Additional Dx ✔Correct answer-Diagnoses, in addition to the principal Dx, that
affect the patient's care
Diagnostic Coding and Reporting Guidelines for Outpatient Services ✔Correct answer-This includes
information about coding signs and symptoms, when to report chronic Dx, ambulatory surgery,
routine output prenatal visits, and more.
What should the coder use to determine the correct code? ✔Correct answer-Use the Alphabetic
Index, and
Tabular List of the ICD-10-CM code book
When attempting to select an ICD-10-CM Dx code, begin by..... ✔Correct answer-Searching for the
main term - such as lesion, burn, etc. In the Alphabetic Index
Follow all cross-references and "see also" entries.
When you have located the code you are seeking, turn to that code in the Tabular List.
Be sure to read each code's ✔Correct answer-Disease definition
Footnotes
,Color-coded prompts,
and other instructions
Read all supplemental information completely to be certain you are choosing the correct code.
Always select a diagnosis ✔Correct answer-To the highest specificity supported by the available
documentation
The first listed diagnosis should describe the...... ✔Correct answer-most significant reason for the
procedure or visit
Generally, the first-listed Dx will be reflective of..... ✔Correct answer-The patient's chief complaint
Secondary diagnoses.. ✔Correct answer-Relevant diseases and conditions, and
Related patient or family hx conditions
When coding pre-existing conditions, make sure... ✔Correct answer-The assigned Dx code
identifies the current reason for medical management.
Do NOT report conditions ✔Correct answer-That no longer exist, or
Do not pertain to the visit
Many patients will have numerous chronic complaints. Report a chronic complaint only when....
✔Correct answer-The chronic condition is treated, or
Becomes an active factor in the patient's care.
Always, Always, Always select ICD-10-CM codes to the highest level of specificity supported by
documentation. Example: ✔Correct answer-Dx Coding for fx of the wrist and hand requires:
- a 5th code character (which specifies location,
-a 6th code character (which specifies the laterality and whether the fx is displaced or no displaced),
and
- a 7th code character (which specifies the episode of care)
Use of codes that describe signs and symptoms are acceptable when.... ✔Correct answer-The
provider has not established a related, definitive dx
Report only _______ Dx. ✔Correct answer-Confirmed
Uncertain Dx described as "___", "____", "____", "____", "____", etc are NOT coded in the
Outpatient setting ✔Correct answer-"probable"
"possible"
"suspected"
"likely"
"rule-out"
, When coding an uncertain Dx, use the following... ✔Correct answer-Highest level of specificity,
Use codes that describe known signs, symptoms, abnormal test results.
Example of uncertain Dx coding ✔Correct answer-If a patient has a breast mass and the provider
suspects breast cancer, you should NOT report breast cancer as the Dx.
Instead report the signs and symptoms, such as breast mass, that prompted the exam.
Only after testing confirms cancer should you report the cancer Dx.
Outpatient encounters with diagnostic tests which have been interpreted by a physician and the final
report is available at the time of coding ✔Correct answer-Report confirmed or definitive Dx
documented in the interpretation
If a definitive Dx is known, do NOT code.... ✔Correct answer-Related signs and symptoms as
additional dx
If the test is positive, ✔Correct answer-you code the findings.
For tests interpreted as normal, code the ✔Correct answer-Condition, symptom(s), or sign(s) that
necessitated the diagnostic study.
If a diagnostic test is ordered without a clear indication of the reason, and the ordering physician is
not available to gather enough information prior to treating the patient,.... ✔Correct answer-You
will want to confirm the order for the physician's reason(s) that the test was ordered.
When provided with both a preoperative and postoperative Dx, always report the ✔Correct
answer-Postoperative Dx code(s) if the pre- and postoperative Dx differ.
______ and ______ attributable to a definitive Dx should NOT be reported separately. ✔Correct
answer-Signs and symptoms
Cite additional signs and symptoms beyond the primary Dx only when ✔Correct answer-Those
signs and symptoms are not interrelated to the disease process.
Report only additional conditions that ✔Correct answer-Affect treatment, and that the provider
documents for the current visit.
Examples of multiple conditions reported with a single code ✔Correct answer-Code category 112
describes hypertension with chronic kidney disease.
Category K81.2 describes acute and chronic cholecystitis
**Two (2) separate codes are not necessary to describe these concurrent conditions.
When selecting multiple conditions reported with a single code, be careful to read all ✔Correct
answer-Inclusion,
Excludes 1, and
Excludes 2 notes to help guide your decision.
ANSWERS|ACTUAL COMPLETE EXAM|ALREADY
GRADED A+ (JUST RELEASED)
__________________ are not a consideration when choosing the right answer. ✔Correct answer-
Individual payer rules
Follow the CPT coding guidelines unless... ✔Correct answer-It is specifically stated in the case note
or exam question that Medicare covers the patient.
Example of reporting additional signs and symptoms attributable to a definitive Dx ✔Correct
answer-The patient presents with shortness of breath. The next day, the MD determines the patient
has pneumonia ; but, feels that the shortness of breath may be due to a cardiac condition.
In such a case, you may still report the shortness of breath as a sign and symptom with the
pneumonia because the MD has documented reason to believe that the conditions are unrelated.
Do NOT ___________ or _____________ information ✔Correct answer-Extrapolate or assume
Select codes ONLY from what is apparent in the available documentation
The ___________ makes the determination as to whether a condition becomes chronic ✔Correct
answer-Doctor
Healthcare providers must begin using the most recent ICD-10-CM code revisions on ________ of
each year, with no ______. ✔Correct answer-October 1st
grace period to transition to the changes.
Coders will select an appropriate code for ______ or _________ (primary) versus _________
(secondary) based on the available documentation. ✔Correct answer-Acute
Sub-acute
Chronic
Example: A torn meniscus (S83. 2-) will become an internal derangement of knee (M23. -) after a
defined period.
If a patient's condition is acute/sub-acute and chronic, a single code does not describe the
combination. ✔Correct answer-The ICD-10-CM code book provides instruction that you would
report the acute (sub-acute) code as first-listed, with the chronic code secondary.
Multiple conditions reported with a single code ✔Correct answer-In some cases ICD-10-CM will
employ a single code to describe 2 or more conditions concurrently, such as primary Dx with an
associated 2ndary process (manifestation),
Or a primary Dx with an associated complication.
,The Official Guidelines note, ✔Correct answer-"A joint effort between the Healthcare provider and
the coder is essential to achieve complete and accurate documentation, code assignment, and
reporting of diagnoses and procedures."
Each ICD-10-CM code assigned must be ✔Correct answer-Supported by documentation linked to
that claim
** (individual dates of service must stand alone)
Coders must be mindful to not.... ✔Correct answer-Assume or extrapolate information from the
medical record
Example: Don't code a condition as acute when it is not documented as such.
Official Guidelines are divided into 4 sections ✔Correct answer-Section I: ICD-10-CM Conventions,
General Coding Guidelines, and
Chapter Specific Guidelines
Section II: Selection of Principal Dx.
Uniform Hospital Discharge Data Set
(UHDDS)
Section III: Rules for Additional Dx
Section IV: Dx Coding and Reporting Guidelines for Outpatient Services
Uniform Hospital Discharge Data Set ✔Correct answer-(UHDDS) : Defines the principle Dx as "that
condition established after study to be chiefly responsible for the admission of the patient to the
hospital for care."
Rules for Reporting Additional Dx ✔Correct answer-Diagnoses, in addition to the principal Dx, that
affect the patient's care
Diagnostic Coding and Reporting Guidelines for Outpatient Services ✔Correct answer-This includes
information about coding signs and symptoms, when to report chronic Dx, ambulatory surgery,
routine output prenatal visits, and more.
What should the coder use to determine the correct code? ✔Correct answer-Use the Alphabetic
Index, and
Tabular List of the ICD-10-CM code book
When attempting to select an ICD-10-CM Dx code, begin by..... ✔Correct answer-Searching for the
main term - such as lesion, burn, etc. In the Alphabetic Index
Follow all cross-references and "see also" entries.
When you have located the code you are seeking, turn to that code in the Tabular List.
Be sure to read each code's ✔Correct answer-Disease definition
Footnotes
,Color-coded prompts,
and other instructions
Read all supplemental information completely to be certain you are choosing the correct code.
Always select a diagnosis ✔Correct answer-To the highest specificity supported by the available
documentation
The first listed diagnosis should describe the...... ✔Correct answer-most significant reason for the
procedure or visit
Generally, the first-listed Dx will be reflective of..... ✔Correct answer-The patient's chief complaint
Secondary diagnoses.. ✔Correct answer-Relevant diseases and conditions, and
Related patient or family hx conditions
When coding pre-existing conditions, make sure... ✔Correct answer-The assigned Dx code
identifies the current reason for medical management.
Do NOT report conditions ✔Correct answer-That no longer exist, or
Do not pertain to the visit
Many patients will have numerous chronic complaints. Report a chronic complaint only when....
✔Correct answer-The chronic condition is treated, or
Becomes an active factor in the patient's care.
Always, Always, Always select ICD-10-CM codes to the highest level of specificity supported by
documentation. Example: ✔Correct answer-Dx Coding for fx of the wrist and hand requires:
- a 5th code character (which specifies location,
-a 6th code character (which specifies the laterality and whether the fx is displaced or no displaced),
and
- a 7th code character (which specifies the episode of care)
Use of codes that describe signs and symptoms are acceptable when.... ✔Correct answer-The
provider has not established a related, definitive dx
Report only _______ Dx. ✔Correct answer-Confirmed
Uncertain Dx described as "___", "____", "____", "____", "____", etc are NOT coded in the
Outpatient setting ✔Correct answer-"probable"
"possible"
"suspected"
"likely"
"rule-out"
, When coding an uncertain Dx, use the following... ✔Correct answer-Highest level of specificity,
Use codes that describe known signs, symptoms, abnormal test results.
Example of uncertain Dx coding ✔Correct answer-If a patient has a breast mass and the provider
suspects breast cancer, you should NOT report breast cancer as the Dx.
Instead report the signs and symptoms, such as breast mass, that prompted the exam.
Only after testing confirms cancer should you report the cancer Dx.
Outpatient encounters with diagnostic tests which have been interpreted by a physician and the final
report is available at the time of coding ✔Correct answer-Report confirmed or definitive Dx
documented in the interpretation
If a definitive Dx is known, do NOT code.... ✔Correct answer-Related signs and symptoms as
additional dx
If the test is positive, ✔Correct answer-you code the findings.
For tests interpreted as normal, code the ✔Correct answer-Condition, symptom(s), or sign(s) that
necessitated the diagnostic study.
If a diagnostic test is ordered without a clear indication of the reason, and the ordering physician is
not available to gather enough information prior to treating the patient,.... ✔Correct answer-You
will want to confirm the order for the physician's reason(s) that the test was ordered.
When provided with both a preoperative and postoperative Dx, always report the ✔Correct
answer-Postoperative Dx code(s) if the pre- and postoperative Dx differ.
______ and ______ attributable to a definitive Dx should NOT be reported separately. ✔Correct
answer-Signs and symptoms
Cite additional signs and symptoms beyond the primary Dx only when ✔Correct answer-Those
signs and symptoms are not interrelated to the disease process.
Report only additional conditions that ✔Correct answer-Affect treatment, and that the provider
documents for the current visit.
Examples of multiple conditions reported with a single code ✔Correct answer-Code category 112
describes hypertension with chronic kidney disease.
Category K81.2 describes acute and chronic cholecystitis
**Two (2) separate codes are not necessary to describe these concurrent conditions.
When selecting multiple conditions reported with a single code, be careful to read all ✔Correct
answer-Inclusion,
Excludes 1, and
Excludes 2 notes to help guide your decision.
