CADS CADS Medical Terminology & Clinical Coding 1 — Questions and Answers
Question 1: Which ICD-10-CM code category is used to document dyspnea as the primary complaint in an ambulance patient care report?
- R06 (Correct answer)
- J45
- I50
- Z00
Correct answer: R06
ICD-10-CM category R06 covers abnormalities of breathing, including dyspnea, which is the appropriate code for respiratory complaints in PCR documentation.
Question 2: The abbreviation 'AMS' in EMS documentation refers to which clinical finding?
- Altered Mental Status (Correct answer)
- Acute Myocardial Syndrome
- Advanced Medical Support
- Airway Management System
Correct answer: Altered Mental Status
AMS stands for Altered Mental Status, a common clinical finding documented in EMS patient care reports when a patient's level of consciousness is abnormal.
Question 3: When documenting a patient with ST-elevation myocardial infarction, which ICD-10-CM code block applies?
- I21 (Correct answer)
- I48
- I10
- R00
Correct answer: I21
ICD-10-CM code block I21 covers ST-elevation myocardial infarction (STEMI), the appropriate classification for acute heart attack with ST changes.
Question 4: Which medical term correctly describes the documentation finding 'absence of breath sounds on one side'?
- Unilateral absence of breath sounds (Correct answer)
- Bilateral crackles
- Rhonchi
- Stridor
Correct answer: Unilateral absence of breath sounds
Unilateral absence of breath sounds is the correct clinical term used in documentation when breath sounds are not heard on one side, often indicating pneumothorax or hemothorax.
Question 5: In NEMSIS-compliant documentation, the element 'ePatient.13' captures which data point?
- Patient's gender
- Patient's date of birth (Correct answer)
- Incident location
- Chief complaint
Correct answer: Patient's date of birth
NEMSIS element ePatient.13 captures the patient's date of birth, a required demographic field in standardized EMS electronic patient care records.
Question 6: Which CPT code range covers basic life support (BLS) ambulance services?
- A0428–A0429 (Correct answer)
- 99281–99285
- A0426–A0427
- 36415–36416
Correct answer: A0428–A0429
HCPCS codes A0428 (BLS non-emergency) and A0429 (BLS emergency) are the correct codes for documenting and billing basic life support ambulance transport.
CADS CADS Medical Terminology & Clinical Coding 1
Which ICD-10-CM code category is used to document dyspnea as the primary complaint in an ambulance patient care report?