Chapter 18
Diagnostic Coding
Multiple Choice Questions
1. | The use of ICD codes is mandated by ____.
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2. | A patient’s diagnosis for a visit, as established by the practitioner, ______.
A. | includes all of the conditions the patient is treated for |
B. | describes the primary condition for which the patient is receiving treatment |
C. | is the chief complaint of the patient |
D. | must comply with WHO terminology guidelines to be accepted by third-party payers |
E. | can be coded directly from the Alphabetic Index |
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3. | How often are the ICD codes updated?
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4. | The Alphabetic Index is organized by ____.
A. | the part of the body involved |
B. | the symptoms displayed by the patient |
C. | codes found in the Tabular List |
D. | diagnosis or condition description |
E. | the severity of the disease or condition |
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5. | When you encounter the word see in the Alphabetic Index, you know that ____.
A. | the term you found is the correct one for the patient's condition |
B. | you must look in another category to find the correct term |
C. | there is more information about the patient's condition somewhere else |
D. | you need to turn to another research source |
E. | the term is considered "not otherwise specified" |
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6. | The Tabular List is mainly organized by ____.
A. | the patient's condition |
B. | the codes found in the Alphabetic Index |
C. | the patient's symptoms |
D. | the body system involved |
E. | the severity of the disease or condition |
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7. | Which of the following ICD-9-CM conventions is used around synonyms, alternative wordings, or explanations?
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8. | Which of the following ICD-9-CM conventions is used in the Tabular List after an incomplete term that needs one of the terms that follow to make it assignable to a given category?
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9. | Which of the following conventions is used in ICD-9 and ICD-10 to indicate that the entries following it further define the content of a preceding entry?
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10. | Which of the following ICD-9 and ICD-10 conventions encloses a series of terms, each of which is modified by the statement that appears to the right of it?
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11. | Which convention is used in ICD-9 and ICD-10 to indicate that an entry is not classified as part of the preceding code?
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12. | Which convention is used in ICD-9 and ICD-10 to set off nonessential or supplementary terms that do not affect the code?
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13. | In both ICD-9 and ICD-10, the convention code first underlying disease means ____.
A. | the code may not be used as the first code |
B. | the disease is not otherwise specified. |
C. | alternative wording must be used |
D. | two codes are required separately to code the diagnosis |
E. | ICD does not provide a code specific enough for the patient's condition |
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14. | What does the ICD convention NEC indicate?
A. | May not be used as the first code |
B. | Not otherwise specified |
C. | Not elsewhere classified |
E. | Two codes must be used together |
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15. | Jenni is a healthy 24-year-old patient who is in the office today for routine obstetric care. The ICD-9 code for routine obstetric care will be found in which of the following series of codes?
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16. | Mary was excited at her last visit to find that she is pregnant. She came in for a prenatal checkup today because she wants to take excellent care of herself and her baby. Everything seems fine, and the physician told her to keep up the good work. The ICD-10 code for routine obstetric care will be found in which of the following series of codes?
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17. | Jeremy is a 44-year-old patient who has been diagnosed with mitral regurgitation. He has been having some shortness of breath lately, so today he is having an echocardiogram to evaluate whether the condition has worsened. The ICD-9 code for Jeremy's procedure today is found in which of the following series of codes?
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18. | Kevin is a 63-year-old patient who was diagnosed with congestive heart failure two years ago. He is having an echocardiogram today so his practitioner can monitor the progression of the disease. The ICD-10 code for Kevin’s procedure today is found in which of the following series of codes?
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19. | Ellie was playing softball and was accidentally hit on the nose with a baseball bat. After examining her nose, the practitioner tells her that her nose is broken and orders a complete radiologic examination of the nasal bones. Where will the ICD-9 code for this radiologic examination be located?
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20. | Eight-year-old Geri climbed the oak tree in her back yard to rescue her cat, who had climbed the tree but could not get back down. Unfortunately, Geri slipped and fell out of the tree and hurt her arm. The lower arm is bent at an odd angle and the bone is visible. The physician diagnoses an open fracture and orders X-rays of the lower arm. Where will you locate the ICD-10 code for this?
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21. | Barry is a healthy 32-year-old established patient who has come in for his annual physical exam. When asked if he has any current problems or complaints, he says no. The ICD-9 code for his visit will be found in which of the following code ranges?
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22. | Mrs. Evans has brought her child in for surgery to correct a cleft palate. Which code range in ICD-10 applies to this procedure?
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23. | Phillip is in the office today for a pre-employment physical that includes a drug test. In which ICD-9 series will you locate the code for this?
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24. | Teresa is being seen today in the urgent care center after spilling a pot of boiling water over her stomach and legs, which resulted in second-degree burns. In which ICD-10 series will you locate the code for her treatment?
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25. | To find the ICD-9 code for anesthesia for surgery to correct a benign prostatic hypertrophy (BPH), you will look in which series?
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26. | To find the ICD-10 code for anesthesia for surgery to correct a benign prostatic hypertrophy (BPH), you will look in which series?
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27. | Which of these is used only in the hospital inpatient setting?
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28. | An easy way to remember when an E code is required is ____.
A. | by noting "see" by a diagnosis code |
B. | if the diagnosis makes you ask "How did that happen?" |
C. | if the diagnosis makes you ask "Why did that occur?" |
D. | by checking for any modifiers to the diagnosis |
E. | when the patient does not have an illness or injury |
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29. | A code in which two diagnoses are included in one code is known as a(n) ____.
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30. | A condition that is of sudden onset or that suddenly becomes much worse is considered a(n) ____.
D. | intermittent condition |
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31. | A condition that is long-standing is considered a(n) ____.
D. | intermittent condition |
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32. | Denise is being seen today because of blurry vision and pain in both eyes. The physician documents that diabetes has damaged the blood vessels in Denise's eyes, resulting in diabetic retinopathy. How will this diagnosis be coded?
A. | The retinopathy is coded first, followed by the diabetes. |
B. | The diabetes is coded first, followed by the retinopathy. |
C. | Only the diabetes should be coded. |
D. | Only the retinopathy should be coded. |
E. | The symptoms of blurry vision and pain should be coded. |
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33. | Diagnosis-related groups, or DRGs, are based on all of the following except ____.
A. | significant procedures performed |
D. | length of hospital stay |
E. | age, sex, and discharge status of the patient |
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34. | The "extra" codes in ICD-9 that tell the third-party payer how an illness or injury came about are known as ____.
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35. | In ICD-9, with which of the following code ranges can E codes be used?
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36. | How many E codes can be used with a single diagnosis code?
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37. | Which of the following statements is not true about E codes?
A. | They are generally used only for the initial treatment of an acute illness or injury. |
B. | All accidents involving motor vehicles require an E code describing the vehicle. |
C. | E codes are always the primary or first diagnosis listed. |
D. | E codes associated with poisonings can be found in the Table of Drugs and Chemicals. |
E. | Burns require an E code to describe how the burn occurred. |
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38. | The purpose of the appendixes of the ICD-9 manual is to ____.
A. | provide helpful research and technical information |
B. | specify the V codes and E codes |
C. | describe congenital defects in more detail |
D. | supplement listings in the Alphabetic Index |
E. | provide helpful hints for code linkage |
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39. | Which appendix in ICD-9 contains a list of the 3-digit categories for occupational hazards divided into subcategories?
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40. | About how many codes does the ICD-10-CM contain?
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41. | How many characters are present in ICD-10 codes?
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42. | What character is used as a placeholder for a nonexistent digit in ICD-10 when a 6th or 7th digit is required for code specificity?
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43. | Which ICD-10 convention describes a condition that is not part of the condition represented by the code, but if the patient actually has both conditions, both may be coded?
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44. | Which of the following statements is not correct about coding HIV positivity?
A. | Requesting a confirmatory serology or culture for HIV is sufficient to code HIV positivity. |
B. | When HIV symptoms are not present and serology is inconclusive, code R75 is assigned. |
C. | Patients who are HIV positive but are currently asymptomatic are assigned code Z21. |
D. | The provider must state "known HIV" or "positive HIV" in order to code HIV positivity. |
E. | Patients who have developed an HIV-related illness should be assigned code B20. |
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45. | The first step in the process of assigning a proper code for a neoplasm in ICD-10 is to consult which of the following?
A. | Appendix C of ICD-10-CM |
C. | The Table of Neoplasms |
D. | Chapter 2, "Neoplasms" |
E. | Chapter 20, "External causes of morbidity" |
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46. | In ICD-10, which has combination codes that include the type of diabetes, what code is used if the type of diabetes is not documented in the medical record and the practitioner cannot be questioned?
A. | Use the ICD-9 code for diabetes instead |
B. | Use the code for type 1 diabetes mellitus |
C. | Use the code for type 2 diabetes mellitus |
D. | Use a code that specifies insulin use |
E. | Use add-on codes to show unspecified diabetes |
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47. | In ICD-10, which chapter contains codes to identify who, what, when, and where an accident or injury occurred?
A. | Chapter 17: Congenital malformations, deformations, and chromosomal abnormalities |
B. | Chapter 18: Symptoms, signs, and abnormal clinical and laboratory findings; not elsewhere classified |
C. | Chapter 19: Injury, poisoning, and certain other consequences of external causes |
D. | Chapter 20: External causes of morbidity |
E. | Chapter 21: Factors influencing health status and contact with health services |
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Fill in the Blank Questions
48. | The ________ Index is organized by the condition, not by the body part in which it occurs. ________________________________________ |
49. | In ICD-9, three-digit categories known as ________ are used for diseases, injuries, and symptoms. ________________________________________ |
50. | The list of abbreviations, punctuation, symbols, typefaces, and instructional notes that appears at the beginning of the ICD and provides guidelines for using the code set are called ________. ________________________________________ |
51. | When "see" appears after a main term, you must look up the term that follows the word “see” in the index. This is an example of a ___________. ________________________________________ |
52. | The primary condition for which a patient is receiving care is communicated to the third-party payer through a(n) ________ code on the healthcare claim. ________________________________________ |
53. | ________ codes are used for injuries resulting from various environmental events. ________________________________________ |
54. | The diseases and injuries in the ________ List of the ICD are organized into chapters according to the source or body system. ________________________________________ |
55. | In ICD-9 the _______ codes are used to identify encounters for reasons other than illness or injury and can be used either as a primary code for an encounter or as an additional code. ________________________________________ |
56. | The ICD-9-CM was originally created for the classification of patient ________ (sickness) and mortality statistics and to provide access for medical research, education, and administration. ________________________________________ |
57. | Patients' descriptions of their medical problems is called their ________ complaint and are documented at each visit. ________________________________________ |
58. | In ICD-10, each category in the Tabular List has 3 characters, and each ________ has 4 or 5 characters, with the final code consisting of up to 7 characters. ________________________________________ |
59. | Unlike outpatient coding, which uses the patient's primary diagnosis, hospital coding uses the _____ diagnosis, which is the condition that was chiefly responsible for the patient's admission to the hospital. ________________________________________ |
60. | Payment for inpatient claims are based on a system known as ________. ________________________________________ |
61. | All ICD-10 codes begin with a(n) ________ character. ________________________________________ |
62. | ICD-10 contains many more ________ codes than ICD-9, which cuts down the need to use multiple codes for a single diagnosis. ________________________________________ |
63. | To assign a proper code for a neoplasm in ICD-10, the documentation must state whether it is benign, ________, in situ, or of uncertain behavior. ________________________________________ |
64. | When hypertension is caused by an underlying condition, two codes are required. The first identifies the underlying ________, or cause, and the second codes the hypertension. ________________________________________ |
65. | After listening to the patient's statements, performing an examination, and evaluating the information received from these sources, the physician establishes a(n) ________ that describes the primary condition for which a patient is receiving care. ________________________________________ |
66. | ICD stands for "International ________ of Diseases." ________________________________________ |
67. | One of the original reasons for the ICD-9-CM was to classify patient morbidity (sickness) and ________ (death) statistics. ________________________________________ |
68. | Additional terms that are needed to select correct codes are indented after the main term in the Alphabetic Index. These terms are called ________. ________________________________________ |
69. | When a practitioner does not document an exact diagnosis, outpatient coding rules require that unclear diagnosis be coded using the ________ that led the patient to seek care, until an absolute diagnosis is made. ________________________________________ |
70. | A(n) ________ diagnosis is used in addition to the primary diagnosis to describe another condition that is also affecting the patient at the time of the visit. ________________________________________ |
Multiple Choice Questions
71. | In ICD-10, in which chapter would a code for an injury diagnosis be found?
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72. | How many chapters are contained in the ICD-10 coding book?
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73. | In ICD-10, which chapter would include the diagnosis codes for congenital malformations, deformations, and chromosomal abnormalities?
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Fill in the Blank Questions
74. | Implementing ICD-10 is meant to allow greater _______ for diagnosis classifications. ________________________________________ |