Fundamentals of Medical Coding Practice Test

These questions are part of the practice quiz. Start practicing

• What is a fee schedule considered in terms of reimbursement methodology?
• The HIPAA security rule establishes standards for which type of health information?
• Which appendix includes clinical examples for codes in the E/M section?
• Which level of anesthesia management is indicated for the highest level of monitoring?
• What is the monthly publication by the AMA that serves as an official coding resource?
• Which document is used to record data about office procedures and services provided to patients?
• Which diagnostic test measures muscle function using a pressure-sensitive tube?
• When unlisted service or procedure codes are reported, what is also required?
• What does the term 'brackets' signify in the ICD-10-CM Tabular List?
• The HIPAA small code set collects information concerning which of the following?
• What does the modifier -22 illustrate in medical coding?
• What do you call the document that summarized information about a patient's discharge from a facility?
• What does the term "conscious sedation" refer to in CPT Appendix G?
• In the ICD-10-CM Tabular List, what is used to enclose abbreviations, synonyms, or explanatory phrases?
• The term used to describe codes that need both the main and subterm clearly documented by the physician is what?
• The portion of the SOAP note that captures the clinician's observations is known as?
• Which quarterly publication is recognized as an official coding resource by the AHA?
• What type of publication do encoders typically represent in medical coding?
• Which of the following is not considered an outpatient setting?
• When a "code first" note is present in the ICD-10-CM tabular list and an underlying condition is documented in the patient record, the _____.
• Which of the following is not reported as a first-listed diagnosis in medical coding?
• What type of catheter is ideal for long-term medication delivery?
• Which phrase is commonly found in a complex diagnosis statement as documented by a physician?
• What is the maximum number of procedures an anesthesiologist or CRNA may direct at one time called?
• A sequela is the residual condition produced after which phase of an illness or injury?
• What is the term for a catheter placed into a vein and connected to a monitor?
• Which coding guideline helps ensure compliance with third-party payer requirements?
• What is the term for laborious conditions under which anesthesia is provided?
• How is the ICD-10-CM index to Diseases and Injuries organized?
• Which instruction in the ICD-10-CM tabular list means "not included here" and indicates a patient may be diagnosed with all conditions at the same time?
• Which legislation is associated with changes made in 2004 related to DMEPOS?
• What is indicated by a bull's eye symbol in the CPT?
• Who is responsible for processing DMEPOS claims for a specific geographic region?
• Which modifier should be used when a procedure was repeated by the same physician due to special circumstances?
• Information applicable to a particular CPT section is located in what part of the document?
• What is documented about each problem assigned to the patient in the SOAP structure?
• What consequence does the False Claims Act impose for knowingly submitting false claims?
• Integrated record reports arranged in chronological order help provide insights for what purpose?
• A fracture site that is not surgically opened and can be treated by manipulation is known as what?
• What can be concluded about the "excludes" note in the ICD-10-CM tabular list?
• What process uses a machine to remove toxic waste from the body?
• What is a small reservoir with a rubber plug attached to the catheter called?
• Which term best describes the list of various conditions and their codes found in ICD-10-CM?
• What type of code is reported on a chargemaster?
• What are "code edit pairs" that cannot be reported on the same claim for payment referred to as?
• The abbreviation NOS (not otherwise specified) means what in medical coding?
• Select the modifier for an unrelated procedure.
• A significant feature of relative value units is their contribution to:
• Chapter 2 of ICD-10-CM includes all codes for which type of condition?
• How is the surgery section organized in medical coding?
• When two primary surgeons perform different parts of a reportable procedure, which modifier is assigned?
• What component is essential for determining the extent of an Evaluation and Management (E/M) service?
• What does the modifier -52 indicate?
• What is the primary function of CPT modifiers?
• What code is designated for multiple procedures performed?
• What term is used to describe a detailed exploration of a patient's history during an E/M service?
• The UB-04 claim form is primarily submitted by which type of facility for reimbursement?
• Which tool is used by hospitals to help identify CPT/HCPCS coding errors?
• Total displacement of a bone from its joint is known as what?
• What does Appendix A of the CPT contain?
• Which appendix of the CPT contains annual coding changes?
• The ICD-10-CM index and its tabular list must both be used during code assignment because the ICD-10-CM index _____.
• What organizes medical nomenclature according to similar conditions and contains codes for each?
• Patient records that consist of handwritten progress notes and automated laboratory results are known as which type of records?
• What happens if a procedure is discontinued prior to anesthesia?
• Which of the following is NOT a benefit of using medical coding software?
• What is the term for a fracture where the broken bone does not protrude through the skin?
• When a bilateral ICD-10-CM code is not provided and the condition is bilateral, ______.
• The modifier -53 is associated with which concept?
• What is essential for the patient record to support codes submitted for reimbursement?
• In what year was the CPT published?
• In regards to monitored anesthesia care, what does the abbreviation -QS stand for?
• The ICD-10-CM Index to Diseases and Injuries contains subterm qualifiers that are listed in what order?
• What component of patient data does the encounter form typically include?
• What instruction in the ICD-10-CM directs the coder to refer to another term to locate the correct code?
• What is a common characteristic of an open fracture?
• What is the significance of code -24 in medical coding?
• When selecting an E/M code, it is important to review patient record documentation to consider up to _____ components.
• Chief complaint, social data, and past medical history are part of which section of the problem-oriented record?
• What year was CPT adopted as part of HCPCS?
• Which of the following best describes the purpose of the False Claims Act?
• What does the Table of Drugs and Chemicals serve as an index for?
• Who must approve DMEPOS claims before they can be processed?
• What is the primary purpose of the National Correct Coding Initiative?
• What term refers to a catheter that is completely implanted under the skin?
• ICD-10-CM codes that indicate laterality specify whether the condition occurs _____.
• Which of the following is a criterion used when assigning diagnosis codes in the coding practice?
• What coding scenario can result from multiple outpatient evaluation encounters in a single day?
• An unlisted service code is used when?
• The term "Emergency room" falls under which E/M place of service?
• What type of information is emphasized through the specificity in ICD-10 codes?
• What are subterms in the ICD-10-CM index used for?
• Section III of the Official Guidelines for Coding and Reporting includes guidelines for the _____.
• Which of the following represents a use of RVUs in medical coding?
• Which type of note is found below the infectious disease code in the ICD-10-CM tabular list, indicating the need for additional coding?
• ICD-10-CM uses what format in its index for ease of reference?
• What reimbursement tool best helps hospital executives determine medical services that have met patient needs over time?
• A patient who is severely diabetic received a below-knee test socket. The code assigned would be found under which section?
• What additional challenge is often noted in cases where anesthesia is needed?
• The patient's feelings and experiences would typically be documented in which part of a SOAP note?
• What does the -G8 code refer to in anesthesia services?
• The development of ICD-10-PCS incorporates an attribute of completeness, meaning what?
• ICD-10-CM codes primarily serve to represent which of the following?
• What is the purpose of a graft in surgical procedures?
• Which code indicates an unrelated evaluation and management service by the same physician during a postoperative period?
• Which catheter is described as a thin, flexible, flow-directed multi-lumen tube positioned in a pulmonary artery?
• Which coding system is primarily used to classify diagnoses in healthcare settings?
• What body area is studied using the contrast agent barium sulfate in radiological procedures?
• Which organization publishes the Current Procedural Terminology (CPT)?
• Who is the person that the student reports to at the health care facility internship site?
• The importance of documentation in patient records relates to which aspect of ICD-10-CM coding?
• What code signifies monitored anesthesia care?
• What does the Administrative, Miscellaneous, and Investigational section of HCPCS Level II codes NOT include?
• Which HCPCS level II modifier indicates services performed by an anesthesiologist?
• ICD-10-CM categories consist of how many characters?
• ICD-10-CM indexes utilize which notation to improve coding accuracy?
• What type of access does a central venous access device provide?
• Which of the following is NOT a purpose of monitored anesthesia care?
• What is the main purpose of the Health Insurance Portability Act of 1966 (HIPAA)?
• What type of entity manages and distributes software-based services over the Internet for coding purposes?
• Which process involves moving healthy tissue from one site to another to replace diseased tissue?
• Which legislation limited exclusions for preexisting conditions?
• What essential information do coders need to report a diagnosis accurately?
• Which of the following is considered a key component of E/M services?
• Which are the four organizations that comprise the cooperating parties that approve the Official Guidelines for Coding and Reporting?
• Which term is used for anesthesia care involving monitoring during less complex procedures?
• ICD-10 coding systems primarily aim to classify data related to what?
• What code represents multiple outpatient hospital evaluation and management encounters on the same date?
• A problem that runs a definite and prescribed course, is transient in nature, and is not likely to permanently alter health status is _____.
• A fracture site that is surgically opened or exposed is referred to as what?
• What type of care service includes physical examination, early detection of disease, family planning, immunization, and treatment of minor illnesses and injuries?
• CPT recognizes _____ types of presenting problems.
• Appendix B in the CPT is important because it...
• ICD-10-CM codes in the Tabular List of Diseases start with which character?
• What term describes the surgical closure of a wound?
• Why might an error be permissible under the False Claims Act?
• What technique involves the application of extreme cold to destroy abnormal tissue?
• What is the name of the injection administered to provide immediate temporary protection against rabies?
• To find a code for orthopedic shoes, which section should be referenced?
• What does the 'practice expense' component in RVUs typically include?
• In medical coding, what term refers to the method of destroying abnormal tissue through extreme cold?
• The history of a patient's disease can be reported as a second code for ICD-10-CM, and it can be found in which chapter?
• What does computer-assisted coding software automatically generate by reading transcribed clinical data?
• Combination codes in ICD-10-CM can be found by referring to which notes?
• Which procedure involves the use of chemicals to destroy diseased tissue?
• Which government area investigates possible cases of DRG creep?
• Revisions to code descriptions are indicated by which symbol?
• Which coding system includes the code for durable medical equipment?
• What type of report typically outlines hospital coding errors identified through audits?
• In ICD-10-CM, three character codes are reported only when there are no further what?
• What type of cannula is inserted into an artery and connected to a monitor?
• Who publishes the International Classification of Diseases (ICD)?
• An electronic health record is best described as a?
• When coding questions arise from a DMEPOS dealer, what should be consulted?
• What is indicated when a procedure requires two primary surgeons?
• What is the focus of the coding conventions typically learned by coders?
• What is the main purpose of HCPCS codes?
• Which modifier indicates that anesthesia was administered by the surgeon?
• How does the False Claims Act contribute to cost control in healthcare?
• Which of the following is NOT a component of relative value units (RVUs)?
• What do General Equivalence Mappings (GEMs) provide?
• Which of the following is NOT a function of the Table of Drugs and Chemicals?
• The coding conventions in ICD-9-CM and ICD-10-CM are designed to ensure what?
• Appendix K of the CPT contains a list of what?
• In the context of anesthesia, what does the modifier "-AA" signify?
• What is the term for surgically rebuilding a body part?
• What is the primary purpose of the ICD-10-CM coding system?
• What does a triangle placed to the left of a code number represent?
• What term describes ICD-10-CM index entries that do not have a specific code in the tabular list?
• What is one result of the greater specificity and clinical information in ICD-10-CM and ICD-10-PCS?
• What is defined as a face-to-face contact between a patient and a health care provider?
• What does the forbidden symbol in CPT indicate?
• According to the Health Insurance Association of America, what is the largest area of health care fraud?
• What surgical technique is indicated for the closure of wounds?
• What are the components included in relative value units (RVUs)?
• What is required for coding orthopedic shoes effectively?
• To indicate that a procedure includes conscious sedation, what symbol is used?
• ICD-10-CM/PCS includes updated medical terminology and classification of diseases to provide better data for what purpose?
• In what year were five-digit CPT codes introduced?
• Stark I and Stark II laws primarily regulate what practice?
• The ICD-10-CM Official Guidelines for Coding and Reporting provide interpretation of what type of guidelines?
• General rules in ICD-10-CM and ICD-10-PCS that guide coding practices are referred to as what?
• Which plan is known as a 401 (K) plan for health care?
• What does the code -G9 indicate regarding a patient’s anesthesia care?
• What element is used to assess the complexity of medical decision-making in E/M services?
• Which of the following modifiers indicates a distinct procedural service?
• What is primarily assessed under relative value units?
• When were HCPCS Level III codes eliminated?
• Topical application of a local anesthetic is classified as which type of anesthesia?
• What are the conditions that must be met for participation within Medicare regulations?
• Which document is used by hospitals to record outpatient encounter data?
• What do companies publish that aids in locating and verifying diagnosis and procedure codes?
• What term refers to a condition that occurs as a result of another medical condition?
• When coding for medical procedures, what is crucial for ensuring codes are correctly assigned?
• What is assigned to each CPT and HCPCS level II code under the OPPS to identify the payment for that code?
• What code is used for medically supervised anesthesia for more than four concurrent procedures?
• Which code is used for bilateral procedures?
• In the CPT index, how are main terms printed?
• Which element is critical for determining the relative value of a medical service?
• Which modifier indicates the patient's physical status at the time anesthesia was administered?
• Manipulation of a fracture is best described as which of the following?
• In order to obtain reimbursement from third-party payers, patient diagnoses must?
• Which coding system is focused on outpatient procedures and services?
• A limited examination of the affected body part or organ system and other symptomatic or related organ systems is an _____ examination.
• Relative value units help in determining payment rates primarily for which group of practitioners?
• What tool is used to capture data on patients in skilled nursing facilities for the minimum data set (MDS)?
• Which of the following refers to a type of service?
• Which of the following is NOT a component of the health record?
• What type of anesthesia typically involves the use of creams or gels applied to the skin?
• What type of note summarizes a patient's care and treatment at the conclusion of their stay in a facility?
• Automated case abstracting software is commonly used by hospitals to?
• A broken bone that can be seen through an open wound is classified as what?
• An ICD-10-CM code is considered _____ if the number of characters required have not been assigned.
• What legislation mandated the payment methodology for durable medical equipment in 1987?
• Which of the following is a characteristic of coding conventions in ICD-10-CM?
• Which of the following is a component of an E/M service?
• ICD-9-CM and ICD-10-CM diagnosis codes are assigned to outpatient and _____ claims for health care financial planning, reimbursement, and statistical purposes.
• Which appendix provides coding details for moderate (conscious) sedation?
• Coding is the assignment of codes to diagnoses, services, and procedures based on what?
• A coder's working knowledge helps ensure accurate coding for which primary purpose?
• What types of services are included in primary care services?
• What coding term would you use for multiple surgical procedures performed during one session?
• How many characters can ICD-10-CM codes have at maximum?
• Which element is crucial for determining the specificity of an ICD-10-CM code?
• Which term describes the attempted reduction or restoration of a fracture or dislocation with manual forces?
• Which of the following best describes the intent of the clinical element in ICD-10-CM?
• Which punctuation in codes indicates additional information is necessary to assign the code properly?
• Which of the following is included in codes for outpatient PPS?
• What is the first character type in valid ICD-10-CM three character category codes?
• Which of the following best describes a patient’s progress notes?
• In the context of coding for bilateral conditions, what does ICD-10-CM specifically emphasize?
• Which modifier can be added to codes for CPT radiology services?
• ICD-10-CM's inclusion terms are found within which types of notes?
• Which of the following is a diagnostic procedure?
• Which of the following is not a qualified diagnosis in medical coding?
• ICD-10-PCS is specifically used to code and classify what type of data?
• Which factor does NOT influence the calculation of RVUs?
• What does the acronym DMEPOS stand for?
• Which of the following statements is true regarding the False Claims Act?
• Section I of the Official Guidelines for Coding and Reporting includes guidelines for the _____.
• What type of codes are listed in Appendix G of the CPT?
• Chapters in ICD-10-CM classify diseases and injuries according to body systems as well as what else?
• Patient record documentation stating "patient has a history of alcohol and drug use as a teenager and smokes one to two packs of cigarettes daily" would be found under which heading?
• What is the dollar amount assigned per geographic location for anesthesia services called?
• Who developed the National Coding Initiative?
• ICD-10-CM Disease and Injury codes describe causes of illness or clinical symptoms exhibited by the patient, and codes assigned must be supported by _____.
• What type of fixation involves hardware inserted through bone and skin, held rigid with a cross brace outside of the body?
• Relative value units are primarily used in which area of healthcare?
• What punctuation is used in the ICD-10-CM index to indicate that an additional term is needed to clarify a code?
• What are used to report product-specific HCPCS codes for obtaining reimbursement associated with implantable device technologies?
• What does a horizontal triangle symbolize in medical coding guidelines?
• Which term describes the use of both electronic and paper records in patient documentation?
• The term clinical in ICD-10-CM modification stresses the need for codes to be more what?
• What code is used for anesthesia services performed personally by an anesthesiologist?
• Which modifier is used to indicate increased procedural services?
• Which element is crucial for the accurate classification of a medical diagnosis?
• What type of service does a consultation in medical coding refer to?
• What is the primary purpose of the guidelines in the CPT?
• Which E/M subsection would be referenced to assign the appropriate code if Dr. Taylor reviewed an x-ray report and discussed results by telephone?