CMC Coding Guidelines & Conventions

Question 1

What does ICD-10-CM stand for?

Accepted Answer

International Classification of Diseases – 10th Revision – Clinical Modification

Answer

ICD-10-CM stands for International Classification of Diseases, 10th Revision, Clinical Modification. This system is used in the United States to code all diagnoses, symptoms, and procedures recorded in conjunction with hospital care. It provides a standardized way to classify diseases for billing, statistical, and research purposes.

Question 2

When coding a diagnosis, which should be reported first?

Accepted Answer

Principal diagnosis

Answer

When coding a diagnosis, the principal diagnosis should always be reported first. 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. All other conditions are considered secondary diagnoses.

Question 3

What symbol in ICD-10-CM indicates that another code is needed to fully describe the condition?

Accepted Answer

Use additional code

Answer

In ICD-10-CM, the 'Use additional code' note indicates that the code selected may not fully describe the patient's condition and that another code is required to provide a complete picture. This convention ensures comprehensive and accurate reporting of diagnoses. It's a crucial instruction for coders to follow to avoid incomplete coding.

Question 4

Which section of the CPT manual contains evaluation and management codes?

Accepted Answer

Evaluation and Management

Answer

The CPT (Current Procedural Terminology) manual is divided into several main sections, and the Evaluation and Management (E/M) section contains codes for physician services related to assessing and managing patient health. These codes are used to report office visits, hospital visits, consultations, and other types of patient encounters. It is typically the first section of the CPT manual.

Question 5

How should a coder handle a diagnosis described as 'probable' or 'suspected' in outpatient coding?

Accepted Answer

Use a symptom code

Answer

In outpatient coding, diagnoses described as 'probable,' 'suspected,' 'possible,' or 'rule out' should not be coded as if they are confirmed. Instead, the coder should report the signs, symptoms, or abnormal test results that led to the suspected diagnosis. This guideline prevents coding for conditions that have not yet been definitively established.

(CMC) Certified Medical Coder Practice Test

(CMC) Certified Medical Coder Practice Test

CMC Coding Guidelines & Conventions