Medical Coding Flashcards
7 cards from real CCDM practice questions. Tap to flip, then mark Knew It or Still Learning — missed cards come back until you master them.
Read the first 7 Medical Coding flashcards as text
In ICD-10-CM, an 'excludes1' note means:
Answer: The excluded code can never be reported with the code in question
An 'Excludes1' note means the conditions cannot occur together, so both codes should never be reported simultaneously.
When a clinical data manager reviews coded adverse event data before database lock, the primary goal of the coding review is to ensure:
Answer: All verbatim terms are accurately mapped to the appropriate MedDRA terms and no coding errors exist
The coding review ensures accuracy and completeness of verbatim-to-MedDRA mappings to support reliable safety analysis before database lock.
A patient's death during a clinical trial is coded as an adverse event. Under MedDRA, 'Death' at the PT level falls under which SOC?
Answer: General disorders and administration site conditions
The MedDRA PT 'Death' is classified under the SOC 'General disorders and administration site conditions.'
Which of the following best describes 'upcoding' in the context of medical billing compliance?
Answer: Assigning a higher-level code than the documentation supports to increase reimbursement
Upcoding is a fraudulent practice of assigning codes representing more complex or expensive services than those actually documented or performed.
In the context of WHO-DD coding, what is the ATC (Anatomical Therapeutic Chemical) classification used for?
Answer: Classifying drugs by the organ system they act on and their therapeutic and chemical properties
The ATC system classifies drugs according to the organ or system they act on and their pharmacological, therapeutic, and chemical properties.
During a coding audit for a Phase III trial, it is discovered that 'headache' was coded to 'Migraine' (a more specific PT) without clinical documentation supporting migraine. This is an example of:
Answer: Over-coding or assumption coding, which violates coding accuracy standards
Assigning a more specific code than the source documentation supports (assumption coding) is a coding accuracy violation that can skew safety data.
Which regulatory guidance document provides recommendations for standardized coding of adverse events in clinical trial safety reporting?
Answer: ICH E2B(R3)
ICH E2B(R3) provides the international standard for electronic transmission of individual case safety reports (ICSRs), including structured adverse event coding.