D521-Introduction to Medical Coding Questions and Answers | Latest Version | 2025/2026 | Correct & Verified

D521-Introduction to Medical Coding Questions and Answers | Latest Version | 2025/2026 | Correct & Verified What is the first step in the medical coding process? Reviewing the patient’s medical record for documentation of diagnoses and procedures. Why are guidelines included in ICD-10-CM coding manuals? They provide instructions on code selection, sequencing, and reporting to ensure uniformity. What is a primary diagnosis? The main condition or reason for the patient’s encounter. What is a secondary diagnosis? A coexisting condition that affects patient care or treatment during the encounter. How are late effects coded in ICD-10-CM? With a separate code indicating the residual condition and another for the original cause. 2 What does the abbreviation “NOS” mean in coding? Not Otherwise Specified What does the abbreviation “NEC” mean in coding? Not Elsewhere Classified What is the role of a coding compliance program? To ensure accurate coding, prevent fraud, and maintain regulatory compliance. How should a coder handle ambiguous documentation? Query the healthcare provider for clarification before assigning a code. What is a principal procedure? The main procedure performed during an inpatient hospital stay for treatment. What is the difference between primary and secondary procedures? Primary procedure is the main treatment; secondary procedures are additional services provided. 3 What is meant by “upcoding”? Assigning a code that results in higher reimbursement than justified by the documentation. Which code set is primarily used to report diagnoses in the United States? ICD-10-CM Which code set is primarily used to report procedures performed in hospitals for inpatient services? ICD-10-PCS Which code set is used to report outpatient procedures and physician services? CPT What is the purpose of HCPCS Level II codes? To report supplies, equipment, and services not covered by CPT codes. What is the definition of a modifier in medical coding? 4 A two-character code added to a CPT or HCPCS code to indicate a special circumstance or alteration of the service. Why is accurate medical coding important for healthcare providers? It ensures proper reimbursement, reduces errors, and maintains compliance with regulations. What is the difference between ICD-10-CM and ICD-10-PCS? ICD-10-CM is used for diagnoses; ICD-10-PCS is used for inpatient procedure coding. What does CPT stand for? Current Procedural Terminology