CBCS Coding and Coding Guidelines 2

Question 1

In CPT E/M coding for office visits, which three key components determine the level of service for new patients?

Accepted Answer

History, physical exam, and medical decision making — all three must meet or exceed the level

Answer

History, chief complaint, and vital signs

Answer

Medical decision making, time, and diagnosis

Answer

Physical exam, ROS, and assessment

Question 2

What is a principal diagnosis in inpatient hospital coding?

Accepted Answer

The condition established after study to be chiefly responsible for the admission of the patient to the hospital

Answer

The condition that was present on admission (POA)

Answer

The most severe diagnosis listed on the claim

Answer

The first diagnosis code entered on the UB-04

Question 3

What does the ICD-10-CM Alphabetic Index instruct you to do when you see 'see also'?

Accepted Answer

Also look up the referenced main term if your current search does not produce a complete code

Answer

Stop coding and use the suggested main term instead

Answer

Always use the alternate code provided after the instruction

Answer

Exclude the condition from coding if the additional term applies

Question 4

What is the correct coding sequence for a patient admitted for sepsis caused by MRSA pneumonia?

Accepted Answer

Code the sepsis first (A41.02 Sepsis due to MRSA), then the pneumonia as the underlying infection

Answer

Code the pneumonia first, then sepsis, then MRSA

Answer

Code only the MRSA (B95.62) as it is the causal organism

Answer

Code only the sepsis; do not separately code the underlying infection

Question 5

What is the function of CPT Category III codes?

Accepted Answer

Temporary codes for emerging technology, services, and procedures used to collect data for FDA approval or coverage decisions

Answer

Codes for supplies and materials beyond those included in service codes

Answer

Codes for non-physician practitioners performing physician-equivalent services

Answer

Supplemental codes used exclusively for hospital outpatient billing

Question 6

When coding a fracture in ICD-10-CM, what information is needed to select the correct 7th character?

Accepted Answer

The encounter type (initial, subsequent, sequela), healing status for subsequent encounters, and for open fractures, the Gustilo classification

Answer

Only the bone that was fractured and the fracture type

Answer

The patient's age and whether surgery was performed

Answer

Only whether the fracture is complete or incomplete