FREE CPMS Medical Coding and Revenue Questions and Answers

Question 1

A physician informs the scribe that the patient has a sprained ankle.
For the most accurate ICD-10-CM coding, which additional detail is most critical for the scribe to document if provided by the physician?

Accepted Answer

The specific ligaments involved and laterality (right/left)

Answer

The patient's preferred pharmacy

Answer

The color of the bruising on the ankle

Answer

The time of day the injury occurred

Question 2

In the context of the healthcare revenue cycle, what is the primary purpose of the International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM) code set?

Accepted Answer

To represent patient diagnoses and establish medical necessity for services rendered.

Answer

To report medical, surgical, and diagnostic procedures and services.

Answer

To identify the provider's level of medical decision making.

Answer

To describe and track durable medical equipment (DME) and supplies.

Question 3

Which of the following best describes how a scribe's detailed documentation of the History of Present Illness (HPI) and Review of Systems (ROS) directly impacts Evaluation and Management (E/M) coding under the 2021 guidelines?

Accepted Answer

It supports the level of Medical Decision Making (MDM) by capturing the complexity of problems addressed.

Answer

It directly determines the final diagnosis code assigned to the patient.

Answer

It is used to bill for the scribe's time separately from the physician's service.

Answer

It automatically generates the CPT code for any procedures performed during the visit.

Question 4

A physician diagnoses a patient with diabetes and performs a foot exam to check for neuropathy. To ensure proper billing and demonstrate medical necessity, the scribe's documentation should clearly:

Accepted Answer

Link the foot exam procedure to the diabetes diagnosis.

Answer

Note the brand of the patient's glucose meter.

Answer

Record the patient's insurance provider information in the clinical note.

Answer

Mention that the patient is due for an annual physical.

Question 5

The term 'upcoding' refers to the fraudulent practice of:

Accepted Answer

Using a billing code for a more complex or expensive service than what was actually provided.

Answer

Billing for a service that was never rendered to the patient.

Answer

Failing to document services thoroughly, leading to a lower-level code being assigned.

Answer

Submitting a claim to a secondary insurer before the primary insurer has paid.

Question 6

Which of the following documentation elements, when captured accurately by a scribe, is essential for supporting a Current Procedural Terminology (CPT) code for a laceration repair?

Accepted Answer

The length, location, and complexity (e.g., simple, intermediate) of the repair.

Answer

The patient's tetanus immunization status.

Answer

The name of the nurse who assisted with the procedure.

Answer

The manufacturer of the suture material used.

A physician informs the scribe that the patient has a sprained ankle.For the most accurate ICD-10-CM coding, which additional detail is most critical for the scribe to document if provided by the physician?

A physician informs the scribe that the patient has a sprained ankle.
For the most accurate ICD-10-CM coding, which additional detail is most critical for the scribe to document if provided by the physician?