Question 1

The coder should rely solely on the discharge summary to capture all of the diagnoses and procedures that were treated and performed.

Accepted Answer

The coder should not rely solely on the discharge summary for coding purposes. They should also review all available medical records, including progress notes, test results, and consultation reports, to ensure accurate coding.

Question 2

Exceptions to the general rule that main terms usually identify disease conditions are Z codes.

Accepted Answer

Z codes are used to identify reasons for encounters that are not related to a disease or injury, such as routine exams or screenings, history of a disease, or personal or family history of a condition.

Question 3

The main term is ____.
A)always identified in italics
B)a review of the patient's hospital course
C)a term identifying disease conditions or injuries
D)a word found in parentheses that enclose explanatory information that does NOT affect the code

Accepted Answer

The main term in a medical code is a term identifying disease conditions or injuries. It is used to locate the code in the coding manual. A) Italics are used for anatomical terms and classification codes. B) A review of the patient's hospital course is not related to coding. D) Parentheses are used to enclose supplementary or explanatory words or phrases that affect the code.

Question 4

The first step in coding the principal diagnosis is to ____.
A)identify the diagnosis and the principal procedure
B)identify main term(s) in the Alphabetic Index
C)review the medical record
D)review any subterms under the main term in the Index

Accepted Answer

The first step in coding the principal diagnosis involves reviewing the medical record to understand the patient's condition, treatments, and outcomes, which then guides the coder in identifying the correct codes.

Question 5

A differential diagnosis is when a patient presents with a symptom that is usually related to only one possible diagnosis.

Accepted Answer

A differential diagnosis involves considering multiple possible diagnoses that could explain a patient's symptoms, rather than just one.

Question 6

Match the following with the correct term or definition.
-Emergency Room
A)Tabular List
B)See also
C)Subterms
D)Discharge summary
E)Coding Clinic
F)ER
G)Differential diagnosis
H)Chief complaint
I)The first basic step in coding the principal diagnosis
J)Nonessential modifiers

Accepted Answer

ER stands for Emergency Room.

Answer: I 
 The first basic step in coding the principal diagnosis is selecting it from the Tabular List.

Answer: J 
 Nonessential modifiers are additional words or phrases that do not affect the code assignment.

Answer: D 
 A discharge summary is a document that summarizes the patient's stay in the hospital and includes information about the diagnosis and treatment received.

Answer: G 
 Differential diagnosis is a process of identifying the possible causes of a patient's symptoms.

Answer: H 
 Chief complaint is the main reason why a patient seeks medical attention.

Answer: A 
 The Tabular List is a part of the ICD coding system that contains a list of codes in numerical order.

Answer: E 
 Coding Clinic is a publication that provides guidance on coding and is usually published by the American Hospital Association or the American Health Information Management Association.

Answer: B 
 See also refers to cross-references to other codes or terms that may be related to the one being looked up.

Answer: C 
 Subterms are terms that are listed under the main term in the Index and provide more specific information on the code to be assigned.

Question 7

The main terms usually are nouns and/or disease conditions.

Accepted Answer

Yes, the main terms in medical language are often nouns and/or disease conditions. For example, "diabetes," "hypertension," "cancer," "pneumonia," "influenza," etc.

Question 8

In the discharge summary,a physician lists the __________ that were evaluated and treated and any procedures that were performed.

Accepted Answer

The answer of In the discharge summary,a physician lists the...

Question 9

When evaluating an ER record,a coder should look for the ____.
A)diagnosis
B)chief complaint
C)probable diagnosis
D)differential diagnosis

Accepted Answer

The answer of When evaluating an ER record,a coder should...

Question 10

The main term in "aplastic anemia" is ____.
A)anemia
B)aplasia
C)aplastic
D)none of the above

Accepted Answer

The main term in "aplastic anemia" is "anemia," as it describes the condition being referred to, with "aplastic" serving as a modifier to specify the type of anemia.

Question 11

Which of the following is/are a reason(s) why the discharge summary is not the only document from which codes are captured?
A)Coders may not have a discharge summary at the time of coding
B)If the patient is in the hospital for a long stay,the attending physician will often be focused only on those diagnoses that occurred in the latter part of the stay
C)Physicians list diagnoses that are not currently being treated and are only in the patient's history
D)All of the options are correct

Accepted Answer

All of the options are correct. Coders may not have a discharge summary at the time of coding, attending physician may focus only on recent diagnoses for long stays, and physicians may include diagnoses that are not currently being treated but are in the patient's history. Therefore, relying solely on the discharge summary may result in incomplete or inaccurate coding.

Question 12

A coder must always remember that,once a term is located in the Alphabetic Index,the code must be verified in the Tabular List.

Accepted Answer

It is important to verify the code in the Tabular List after locating the term in the Alphabetic Index to ensure accurate coding.

Question 13

The __________,if available,is the first step in the process of record review for code selection.

Accepted Answer

The answer of The __________,if available,is the first step in...

Question 14

To be sure you have the correct diagnosis code,it is very important to go to the Alphabetic Index first and then to the Tabular List.

Accepted Answer

This statement is true. The Alphabetic Index provides a list of possible codes based on the description of the diagnosis or condition, and the Tabular List provides the final code selection and any instructional notes. It is important to reference both to ensure accurate coding.

Question 15

The admitting diagnosis is usually a sign or a symptom.

Accepted Answer

The answer of The admitting diagnosis is usually a sign...

Question 16

The main term for procedures in ICD-10-CM is identified by the ____.
A)anatomic site
B)place of incision
C)procedure performed
D)none of the above are correct

Accepted Answer

The main term for procedures in ICD-10-CM is identified by the procedure performed, not the anatomic site or place of incision.

Question 17

What is the main term in the procedure "vaginal hysterectomy"?
A)Vaginal
B)Hysterectomy
C)Vaginal hysterectomy
D)None of the above

Accepted Answer

The main term in the procedure is "hysterectomy," which refers to the surgical removal of the uterus. "Vaginal" simply describes the approach used for the surgery, as the uterus is removed through the vagina rather than through an abdominal incision. Therefore, the correct choice is B - Hysterectomy.

Question 18

Which of the following is a basic step in coding?
A)Review the medical record
B)Identify main term(s) in the Alphabetic Index
C)Assign codes to the highest level of specificity by verifying in the Tabular
D)All of the options are correct

Accepted Answer

All of the options are correct. Reviewing the medical record, identifying main terms in the alphabetic index, and assigning codes to the highest level of specificity by verifying in the tabular are all basic steps in coding.

Question 19

Match the following with the correct term or definition.
-Synopsis of the events of a patient's hospital encounter
A)Tabular List
B)See also
C)Subterms
D)Discharge summary
E)Coding Clinic
F)ER
G)Differential diagnosis
H)Chief complaint
I)The first basic step in coding the principal diagnosis
J)Nonessential modifiers

Accepted Answer

A discharge summary is a synopsis of the events of a patient's hospital encounter, including the reason for admission, significant findings, procedures performed, and the patient's condition at discharge.

Answer: G 
 Differential diagnosis is a process of identifying possible causes of a patient's symptoms or condition by comparing and contrasting the features of different diseases.

Answer: H 
 Chief complaint is the primary reason for a patient seeking medical attention, as reported by the patient themselves or their accompanying caregiver.

Answer: I 
 The first basic step in coding the principal diagnosis is determining the reason for the patient's encounter, also known as the principal diagnosis.

Answer: J 
 Nonessential modifiers are additional descriptors that do not affect the assignment of a diagnosis code, but provide additional information to support clinical documentation.

Question 20

When assigning a procedure code in ICD-10-PCS,the coder must first start with the Alphabetic Index.

Accepted Answer

In ICD-10-PCS, coders are not required to start with the Alphabetic Index; they can directly use the Tables to construct the code.

Quiz 4: Basic Steps of Coding

The coder should rely solely on the discharge summary to capture all of the diagnoses and procedures that were treated and performed.

Exceptions to the general rule that main terms usually identify disease conditions are Z codes.

The main term is ____.

The first step in coding the principal diagnosis is to ____.

A differential diagnosis is when a patient presents with a symptom that is usually related to only one possible diagnosis.

Match the following with the correct term or definition. -Emergency Room

The main terms usually are nouns and/or disease conditions.

In the discharge summary,a physician lists the __________ that were evaluated and treated and any procedures that were performed.

When evaluating an ER record,a coder should look for the ____.

The main term in "aplastic anemia" is ____.

Which of the following is/are a reason(s) why the discharge summary is not the only document from which codes are captured?

A coder must always remember that,once a term is located in the Alphabetic Index,the code must be verified in the Tabular List.

The __________,if available,is the first step in the process of record review for code selection.

To be sure you have the correct diagnosis code,it is very important to go to the Alphabetic Index first and then to the Tabular List.

The admitting diagnosis is usually a sign or a symptom.

The main term for procedures in ICD-10-CM is identified by the ____.

What is the main term in the procedure "vaginal hysterectomy"?

Which of the following is a basic step in coding?

Match the following with the correct term or definition. -Synopsis of the events of a patient's hospital encounter

When assigning a procedure code in ICD-10-PCS,the coder must first start with the Alphabetic Index.