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

For new patients, all three key components (history, physical examination, and medical decision making) must meet or exceed the requirements for the selected level of service.

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 principal diagnosis is defined as the condition established after study to be chiefly responsible for occasioning the admission of the patient to the hospital for care.

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

'See also' in the Alphabetic Index directs the coder to look up an additional main term if the current index entry does not provide complete coding information.

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

When sepsis and a localized infection (like pneumonia) are present, ICD-10-CM guidelines direct coders to sequence the sepsis code first, followed by a code for the localized 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

CPT Category III codes (four digits + letter T) are temporary codes for new and experimental services. They are used to collect data and track utilization to support FDA approval or payer coverage decisions.

(CBCS) Certified Billing and Coding Specialist Practice Test

(CBCS) Certified Billing and Coding Specialist Practice Test

CBCS Coding and Coding Guidelines 2