AHIMA Medical Coding and Classification 3 — Questions and Answers
Question 1: What is the purpose of an Encoder in health information management?
- To physically store health records
- To electronically assign and validate diagnosis and procedure codes (Correct answer)
- To calculate patient billing totals
- To manage patient scheduling
Correct answer: To electronically assign and validate diagnosis and procedure codes
An encoder is software that assists coders in selecting and validating ICD, CPT, and HCPCS codes.
Question 2: In ICD-10-PCS, how many characters does every procedure code contain?
- 5
- 6
- 7 (Correct answer)
- 8
Correct answer: 7
Every ICD-10-PCS code is exactly 7 alphanumeric characters, with each character representing a specific axis of classification.
Question 3: Which root operation in ICD-10-PCS describes cutting out or off, without replacement, a portion of a body part?
- Excision (Correct answer)
- Resection
- Destruction
- Detachment
Correct answer: Excision
Excision (value B) involves cutting out or off a portion of a body part without replacement.
Question 4: Which of the following best describes a 'complication or comorbidity' (CC) in MS-DRG assignment?
- Any chronic condition present on admission
- A secondary condition that increases the complexity of care and resource use (Correct answer)
- A condition that is the principal diagnosis
- An injury caused by the patient's fall in the hospital
Correct answer: A secondary condition that increases the complexity of care and resource use
A CC is a secondary diagnosis that increases the severity of illness and expected resource consumption, affecting MS-DRG assignment.
Question 5: What is the ICD-10-CM code category for Type 2 diabetes mellitus?
- E10
- E11 (Correct answer)
- E12
- E13
Correct answer: E11
E11 is the ICD-10-CM category for Type 2 diabetes mellitus, including all its manifestations and complications.
Question 6: Which CPT modifier indicates a service was performed by a resident under the supervision of a teaching physician?
- -GC
- -GE (Correct answer)
- -GX
- -GT
Correct answer: -GE
Modifier -GE indicates that a service was rendered by a resident without the presence of a teaching physician under the primary care exception.
Question 7: In outpatient facility coding, when should POA (Present on Admission) indicators be reported?
- Only for Medicaid claims
- For all diagnosis codes on inpatient acute care claims (Correct answer)
- Only for principal diagnoses
- For all diagnosis codes on all claim types
Correct answer: For all diagnosis codes on inpatient acute care claims
POA indicators are required for all diagnosis codes on inpatient acute care hospital claims submitted to Medicare.
AHIMA Medical Coding and Classification 3
What is the purpose of an Encoder in health information management?