Medical Coding Principles Flashcards
7 cards from real RHIT 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 Principles flashcards as text
Which coding system is used primarily for outpatient and physician office procedure coding in the United States?
Answer: CPT (Current Procedural Terminology)
CPT, maintained by the AMA, is the standard system for coding outpatient procedures and physician services.
In ICD-10-PCS, which root operation would be assigned for the surgical removal of a kidney?
Answer: Resection
Resection means cutting out or off all of a body part without replacement, which applies to complete organ removal.
What is a 'CC' (complication or comorbidity) in the context of MS-DRG assignment?
Answer: A secondary diagnosis that substantially increases hospital resource use
CCs are secondary diagnoses that increase resource consumption and affect MS-DRG grouping and hospital reimbursement.
Under outpatient coding guidelines, which diagnosis should be reported first for a patient presenting with chest pain who is ruled out for MI?
Answer: Chest pain — the sign/symptom that led to the encounter
For outpatients, signs and symptoms are coded when a definitive diagnosis has not been confirmed.
A modifier -25 is appended to an E/M code on the same day as a minor procedure. What does this indicate?
Answer: A significant, separately identifiable E/M service was performed by the same physician on the same day as the procedure
Modifier -25 signals that the E/M service was distinct from the procedure and warrants separate reimbursement.
Which Z code category is used to capture screening examinations for conditions in patients with no signs or symptoms?
Answer: Z00–Z13 (Encounters for examinations)
ICD-10-CM Z00–Z13 includes codes for routine and screening examinations in asymptomatic patients.
When a patient is admitted for chemotherapy and also has the malignancy being treated, what is the correct principal diagnosis?
Answer: The encounter for antineoplastic chemotherapy (Z51.11)
Per ICD-10-CM guidelines, when the purpose of the encounter is chemotherapy, Z51.11 is sequenced as principal diagnosis.