CCDM Medical Coding 3 — Questions and Answers
Question 1: When autocoding software suggests a MedDRA code for a verbatim adverse event term, what step must a trained coder take before accepting it?
- Review the suggestion for clinical appropriateness before accepting (Correct answer)
- Accept it automatically if the confidence score exceeds 80%
- Send it to the sponsor for approval without review
- Replace it with the LLT regardless of the PT suggestion
Correct answer: Review the suggestion for clinical appropriateness before accepting
Autocoding suggestions must always be reviewed by a qualified coder to confirm clinical appropriateness before acceptance.
Question 2: In MedDRA, which System Organ Class (SOC) would 'Myocardial infarction' most appropriately fall under?
- Cardiac disorders (Correct answer)
- Vascular disorders
- General disorders
- Respiratory disorders
Correct answer: Cardiac disorders
Myocardial infarction is classified under the 'Cardiac disorders' SOC in MedDRA.
Question 3: A CCDM candidate reviewing a coding audit finds that two coders assigned different MedDRA PTs to the same verbatim term. This represents a failure in:
- Inter-rater coding consistency (Correct answer)
- Database lock procedures
- Data entry transcription
- SAE reconciliation
Correct answer: Inter-rater coding consistency
When two coders assign different codes to the same verbatim term, it indicates a lack of inter-rater consistency, which must be addressed through training or a coding guide.
Question 4: What is the correct ICD-10-CM code sequencing rule for a patient admitted for chemotherapy for cancer?
- Sequence the encounter for chemotherapy (Z51.11) as the principal diagnosis (Correct answer)
- Sequence the cancer as the principal diagnosis
- Code only the adverse effects of chemotherapy
- Sequence the most severe complication first
Correct answer: Sequence the encounter for chemotherapy (Z51.11) as the principal diagnosis
When the reason for admission is chemotherapy, ICD-10-CM directs coding Z51.11 as the principal diagnosis, with the cancer coded additionally.
Question 5: SNOMED CT is used in clinical data management primarily for:
- Coding clinical findings, diagnoses, and procedures in EHR systems (Correct answer)
- Billing outpatient procedures to insurance
- Classifying drugs for pharmacovigilance
- Organizing laboratory reference ranges
Correct answer: Coding clinical findings, diagnoses, and procedures in EHR systems
SNOMED CT provides a comprehensive clinical terminology for EHR systems, covering findings, diagnoses, procedures, and more.
Question 6: In CPT coding, what does the term 'unbundling' refer to?
- Billing separately for services that should be coded together under one comprehensive code (Correct answer)
- Combining multiple procedure codes into one
- Using a modifier to indicate reduced services
- Submitting claims for services not yet rendered
Correct answer: Billing separately for services that should be coded together under one comprehensive code
Unbundling is the improper practice of reporting multiple codes for components of a procedure that should be billed as a single comprehensive code.
Question 7: Which MedDRA version update practice is required when a clinical trial spans multiple MedDRA version releases?
- Recoding all terms to the new version per a documented version upgrade plan (Correct answer)
- Keeping original version codes for the entire trial duration
- Using only the most current version for new events, retaining old codes for prior events
- Requesting a waiver from the regulatory authority
Correct answer: Recoding all terms to the new version per a documented version upgrade plan
Regulatory guidance and ICH E2B require that a documented MedDRA version upgrade plan be followed to recode all terms consistently when updating versions mid-trial.
CCDM Medical Coding 3
When autocoding software suggests a MedDRA code for a verbatim adverse event term, what step must a trained coder take before accepting it?