RHIT Medical Coding Principles 5

Question 1

Which coding system is used primarily for outpatient and physician office procedure coding in the United States?

Accepted Answer

CPT (Current Procedural Terminology)

Answer

ICD-10-PCS

Answer

SNOMED CT

Answer

ICD-10-CM

Question 2

In ICD-10-PCS, which root operation would be assigned for the surgical removal of a kidney?

Accepted Answer

Resection

Answer

Excision

Answer

Extraction

Answer

Destruction

Question 3

What is a 'CC' (complication or comorbidity) in the context of MS-DRG assignment?

Accepted Answer

A secondary diagnosis that substantially increases hospital resource use

Answer

Any documented chronic disease

Answer

A principal diagnosis that requires surgical intervention

Answer

A laboratory finding noted in the record

Question 4

Under outpatient coding guidelines, which diagnosis should be reported first for a patient presenting with chest pain who is ruled out for MI?

Accepted Answer

Chest pain — the sign/symptom that led to the encounter

Answer

Acute MI (since it was ruled out)

Answer

Atherosclerosis as the likely etiology

Answer

A Z code for observation

Question 5

A modifier -25 is appended to an E/M code on the same day as a minor procedure. What does this indicate?

Accepted Answer

A significant, separately identifiable E/M service was performed by the same physician on the same day as the procedure

Answer

The E/M was a pre-operative evaluation only

Answer

The procedure was bilateral

Answer

The E/M service was provided by a different physician

Question 6

Which Z code category is used to capture screening examinations for conditions in patients with no signs or symptoms?

Accepted Answer

Z00–Z13 (Encounters for examinations)

Answer

Z23 (Immunizations)

Answer

Z77–Z99 (Health hazard status)

Answer

Z55–Z65 (Social determinants)

Question 7

When a patient is admitted for chemotherapy and also has the malignancy being treated, what is the correct principal diagnosis?

Accepted Answer

The encounter for antineoplastic chemotherapy (Z51.11)

Answer

The malignancy

Answer

A chemotherapy complication code

Answer

The secondary site if metastasis is present