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

CPT, maintained by the AMA, is the standard system for coding outpatient procedures and physician services.

Question 2

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

Accepted Answer

Resection

Answer

Resection means cutting out or off all of a body part without replacement, which applies to complete organ removal.

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

CCs are secondary diagnoses that increase resource consumption and affect MS-DRG grouping and hospital reimbursement.

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

For outpatients, signs and symptoms are coded when a definitive diagnosis has not been confirmed.

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

Modifier -25 signals that the E/M service was distinct from the procedure and warrants separate reimbursement.

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