Clinical Classification Systems and Coding Flashcards
7 cards from real RHIA practice questions. Tap to flip, then mark Knew It or Still Learning — missed cards come back until you master them.
Read the first 7 Clinical Classification Systems and Coding flashcards as text
Clinical Documentation Improvement (CDI) programs primarily aim to achieve which goal?
Answer: Ensure physician documentation accurately reflects the patient's clinical condition for coding
CDI programs work prospectively to ensure that physician documentation is complete, accurate, and specific enough to support precise coding and appropriate reimbursement.
A coding compliance audit that compares coded data against the source documentation is called a:
Answer: Retrospective audit
A retrospective audit is conducted after the patient is discharged, reviewing the coded data against the medical record documentation to identify coding errors.
Which of the following correctly describes the 'Excludes2' note in ICD-10-CM?
Answer: The excluded condition is not included here but may be reported together if both conditions exist
Excludes2 means the excluded condition is not included in the code but it is acceptable to assign both codes together when the patient has both conditions simultaneously.
Under ICD-10-PCS, all procedure codes have exactly how many characters?
Answer: 7
Every ICD-10-PCS code is exactly 7 characters long, with each character representing a specific axis of classification such as section, body system, root operation, body part, approach, device, and qualifier.
When a patient is admitted as an inpatient following an outpatient procedure that results in a complication, which diagnosis is sequenced as principal?
Answer: The complication that caused the inpatient admission
When an outpatient procedure leads to a complication requiring inpatient admission, the complication is sequenced as the principal diagnosis because it is the condition chiefly responsible for the admission.
The Cooperating Parties responsible for maintaining the ICD-10-CM Official Guidelines include all of the following EXCEPT:
Answer: AMA
The four Cooperating Parties for ICD-10-CM are AHIMA, AHA, CMS, and NCHS — the AMA maintains CPT codes and is not one of the ICD-10-CM cooperating parties.
In ICD-10-CM, the 7th character 'A' for fracture codes indicates the encounter is:
Answer: Initial encounter for active treatment of the fracture
The 7th character 'A' designates an initial encounter, used while the patient is receiving active treatment for the fracture, regardless of whether the provider is seeing the patient for the first time.