Florida Medical Coding Specialist Exam
Questions with Correct Answers
(Verified Answers) Plus Rationales 2026
Q&A | Instant Download Pdf
1. A patient presents to the emergency department with acute chest pain. After
evaluation, the physician determines the symptoms are caused by
gastroesophageal reflux disease (GERD). Which diagnosis should be coded as the
primary diagnosis?
A. Chest pain
B. GERD
C. Rule-out myocardial infarction
D. History of chest pain
Answer: B
Rationale: The confirmed diagnosis established after evaluation is coded instead
of the symptom when the symptom is integral to the diagnosed condition.
2. A physician documents "Type 2 diabetes mellitus with diabetic chronic kidney
disease." What is the most appropriate coding approach?
A. Code diabetes only
B. Code chronic kidney disease only
C. Assign combination diabetes code and additional CKD stage code if
documented
D. Assign symptom codes only
Answer: C
Rationale: ICD-10-CM provides combination codes for diabetes with chronic kidney
disease and requires additional staging when documented.
,3. A patient undergoes excision of a benign skin lesion from the right forearm
with simple closure. What factor is most important when selecting the procedure
code?
A. Patient age
B. Lesion size and anatomical location
C. Insurance type
D. Physician specialty
Answer: B
Rationale: Excision coding depends primarily on lesion size and location.
4. Which documentation element is most critical for accurate CPT coding of an
office visit?
A. Patient's occupation
B. Medical decision-making, history, and/or time as applicable under current
guidelines
C. Insurance carrier
D. Marital status
Answer: B
Rationale: Evaluation and Management coding relies on documented service
components under current CPT guidelines.
5. A coder identifies conflicting documentation between the operative report and
discharge summary. What is the best action?
A. Code from the discharge summary only
B. Query the provider for clarification
C. Select the highest-paying code
D. Ignore the discrepancy
Answer: B
Rationale: Provider clarification ensures coding accuracy and compliance.
6. A physician documents "suspected bacterial pneumonia" in an inpatient
discharge record. How should this diagnosis be handled?
, A. Code only the symptoms
B. Code the suspected condition according to inpatient reporting guidelines
C. Omit the diagnosis entirely
D. Code as history of pneumonia
Answer: B
Rationale: In inpatient coding, uncertain diagnoses documented at discharge may
be coded as if established.
7. Which coding system is primarily used to report physician services?
A. ICD-10-PCS
B. CPT
C. DRG
D. NDC
Answer: B
Rationale: CPT codes are used for reporting physician and outpatient services.
8. A patient receives a screening colonoscopy during which a polyp is discovered
and removed. How should coding reflect the encounter?
A. Screening only
B. Diagnostic procedure only
C. Screening indication with appropriate procedure coding reflecting polyp
removal
D. Symptom coding only
Answer: C
Rationale: The encounter began as a screening and became therapeutic when a
lesion was removed.
9. What is the primary purpose of ICD-10-CM diagnosis codes?
A. Determine physician salaries
B. Describe diseases, conditions, injuries, and health factors
C. Calculate drug dosages
D. Schedule appointments
Questions with Correct Answers
(Verified Answers) Plus Rationales 2026
Q&A | Instant Download Pdf
1. A patient presents to the emergency department with acute chest pain. After
evaluation, the physician determines the symptoms are caused by
gastroesophageal reflux disease (GERD). Which diagnosis should be coded as the
primary diagnosis?
A. Chest pain
B. GERD
C. Rule-out myocardial infarction
D. History of chest pain
Answer: B
Rationale: The confirmed diagnosis established after evaluation is coded instead
of the symptom when the symptom is integral to the diagnosed condition.
2. A physician documents "Type 2 diabetes mellitus with diabetic chronic kidney
disease." What is the most appropriate coding approach?
A. Code diabetes only
B. Code chronic kidney disease only
C. Assign combination diabetes code and additional CKD stage code if
documented
D. Assign symptom codes only
Answer: C
Rationale: ICD-10-CM provides combination codes for diabetes with chronic kidney
disease and requires additional staging when documented.
,3. A patient undergoes excision of a benign skin lesion from the right forearm
with simple closure. What factor is most important when selecting the procedure
code?
A. Patient age
B. Lesion size and anatomical location
C. Insurance type
D. Physician specialty
Answer: B
Rationale: Excision coding depends primarily on lesion size and location.
4. Which documentation element is most critical for accurate CPT coding of an
office visit?
A. Patient's occupation
B. Medical decision-making, history, and/or time as applicable under current
guidelines
C. Insurance carrier
D. Marital status
Answer: B
Rationale: Evaluation and Management coding relies on documented service
components under current CPT guidelines.
5. A coder identifies conflicting documentation between the operative report and
discharge summary. What is the best action?
A. Code from the discharge summary only
B. Query the provider for clarification
C. Select the highest-paying code
D. Ignore the discrepancy
Answer: B
Rationale: Provider clarification ensures coding accuracy and compliance.
6. A physician documents "suspected bacterial pneumonia" in an inpatient
discharge record. How should this diagnosis be handled?
, A. Code only the symptoms
B. Code the suspected condition according to inpatient reporting guidelines
C. Omit the diagnosis entirely
D. Code as history of pneumonia
Answer: B
Rationale: In inpatient coding, uncertain diagnoses documented at discharge may
be coded as if established.
7. Which coding system is primarily used to report physician services?
A. ICD-10-PCS
B. CPT
C. DRG
D. NDC
Answer: B
Rationale: CPT codes are used for reporting physician and outpatient services.
8. A patient receives a screening colonoscopy during which a polyp is discovered
and removed. How should coding reflect the encounter?
A. Screening only
B. Diagnostic procedure only
C. Screening indication with appropriate procedure coding reflecting polyp
removal
D. Symptom coding only
Answer: C
Rationale: The encounter began as a screening and became therapeutic when a
lesion was removed.
9. What is the primary purpose of ICD-10-CM diagnosis codes?
A. Determine physician salaries
B. Describe diseases, conditions, injuries, and health factors
C. Calculate drug dosages
D. Schedule appointments
