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1. What is the main reason that insurance companies are hesitant to push for a quick release of
the new ICD-10 coding classification system?
A. Difficulty in learning the new system B. Cost of implementing
C. Lack of government support D. Instability of the new system
2. E codes are used to indicate which of the following?
A. Where an accident occurred B. How an accident occurred
C. Whether a drug overdose was accidental or purposeful D. All of the above
3. Which of the following best describes late effects?
A. Residual effects that remain after the acute phase of an injury or illness
B. Effects that are always coded alone
C. Effects categorized according to the nature and time of the disease, condition, or injury
D. E codes that describe where the injury, illness, or condition occurred
4. When two or more diagnoses equally meet the criteria for principal diagnosis, what action
should the coder take?
A. Code both diagnoses with either of the diagnoses sequenced first.
B. Code both of the diagnoses, sequencing the codes based on which diagnosis the physician
listed first on the discharge sheet.
C. Code only the diagnosis most closely related to the treatment.
D. Code only the diagnosis that’s the most resource-intensive.
5. In an acute care hospital, when is it appropriate to assign a code such as 794.31—abnormal
A. When the laboratory or testing report shows that the abnormal finding meets Uniform
Hospital Discharge Data Set (UHDDS) criteria
B. When the physician has documented the abnormal finding in the Progress Notes
C. When the physician hasn’t been able to arrive at a diagnosis, and the diagnosis meets the
guidelines for that particular code
D. It’s never appropriate to assign codes of this type for an acute care setting
6. Which of the following wouldn’t be a valid principal diagnosis?
A. 873.42 C. 496
B. E880.9 D. V25.1
7. Which of the following codes fall under the category of providing codes for reporting factors
influencing health status and health service?
A. V67.4 C. 47.09
B. E884.2 D. A4509
8. Unknown causes of morbidity or mortality should be coded only when
A. the physician documents them on laboratory reports.
B. a more definitive diagnosis isn’t available.
C. reporting acute care hospital codes.
D. they meet UHDDS guidelines.
9. Which of the following scenarios could be classified within code ranges 960–979?
A. Patient has lethargy for unintentionally taking too much of her prescribed sleeping pill.
B. Patient had an allergic reaction to her normal dose of antihistamine.
C. Patient experienced lightheadedness due to the interaction of two drugs prescribed by her
D. Patient is experiencing increased heart rate due to daily dose of Valium that has been
taken as prescribed.
10. A patient was admitted to the hospital with a deep burn to the dermis of the arm. For coding
purposes, you would classify this condition as
A. a first-degree burn. B. a second-degree burn.
C. a third-degree burn. D. undeterminable until the physician clarified with more information.
1. Which of the following code categories should be chosen over codes from other chapters for
the same condition?
A. Complications of pregnancy B. Neoplasms
C. Blood disorders D. Metabolic and nutritional diseases
2. Pyuria or bacteria in the urine should be coded to
A. 790.7. C. 599.0.
B. 038.8. D. 112.5.
3. A patient returns to learn the results of an HIV test, which are negative. Which code is listed
as the reason for the encounter?
A. V65.44 C. 042
B. 795.71 D. V08
4. A patient has a condition wherein the body fails to produce insulin. She requires daily insulin
shots for control that seem to stabilize the condition. She isn’t experiencing any significant
health issues. This condition is coded as
A. 250.01. C. 250.02.
B. 250.00. D. 250.03.
5. A patient is experiencing diabetic nephropathy with hypertensive renal disease and renal
failure. How many codes would be assigned for this patient?
A. 1 C. 3
B. 2 D. 4
6. Hypopotassemia is coded as
A. 266.5. C. 276.8.
B. 244.0. D. 251.2.
7. Conditions that have a decrease in hemoglobin levels in the blood can be coded to Chapter
D. Need more information
8. When should acute blood loss anemia following surgery be coded as a complication of the
A. Whenever there’s a large amount of blood loss following a surgery
B. When the physician states that the large amount of blood loss is due to the surgery and
causing the anemia
C. When anemia follows surgery and hemoglobin levels are elevated beyond the normal
D. Never. Anemia is never considered a complication; instead, it’s considered a disease
9. Which of the following should be used as a guideline when coding diabetes as uncontrolled
A. Blood glucose levels outside of the normal range as documented in the patient’s medical
B. Physician documentation stating uncontrolled or controlled
C. The need for daily insulin injections
D. Any of the above
10. When coding infectious and parasitic diseases,
A. a second code is assigned to indicate the causative organism.
B. fourth digits or additional codes may indicate the causative organism(s).
C. code categories 041–079 as principal, with a fourth digit indicating the causative
D. optional E codes are used to indicate the causative organism.
1. Conditions such as myocardial infarction and angina pectoris are included in which code
A. 410–414 C. 400–410
B. 434–497 D. 417–427
2. A myocardial infarction that occurred three weeks ago should be coded to category
A. 413. C. 411.
B. 412. D. 410.
3. Don’t assign code 412 as a secondary code when
A. current ischemic heart disease is present.
B. the physician documents “healed MI.”
C. a previous heart attack is indicated by an electrocardiogram (EKG) and physician
D. a past MI is causing no problems for the current admission.
4. Which of the following is the appropriate coding and sequencing (if applicable) for a diagnosis
of dementia without behavioral disturbance due to Alzheimer’s disease?
A. 294.1 C. 294.1, 331.0
B. 331.0, 294.10 D. 331.0
5. One of the patient’s diagnoses is listed as alcoholism in remission. Which of the following
codes should be reported for this condition?
A. 303.03 C. 303.93
B. 305.0 D. V11.3
6. A right-handed patient has right-sided hemiplegia from a current, unspecified CVA that clears
before patient discharge. Which of the following could be the correct code assignment(s) and
sequencing (if applicable)?
A. 436 C. 438.21
B. 436, 342.91 D. 438.21, 342.91
7. Bacterial meningitis due to pneumococcus infection should be categorized to
A. one code.
B. two codes.
C. three codes.
D. no codes until the physician is queried for more information.
8. Code seizures and convulsions to category
A. 345. C. 436.
B. 780. D. Need more information
9. Which of the following are examples of codes that can be assigned to the same patient for the
A. 507.0 and 480.9 C. 496 and 493.2
B. 491.20 and 491.21 D. 506.0 and 506.9
10. When a patient is admitted in respiratory failure due to an acute, nonrespiratory condition,
which of the following actions should the coder take?
A. Code respiratory failure as the principal diagnosis and sequenced first.
B. Code acute, nonrespiratory condition as the principal diagnosis and sequenced first.
C. Code respiratory condition causing the respiratory failure as the principal diagnosis and
D. Query the physician for appropriate sequencing.
1. Vomiting of blood may indicate which of the following types of hemorrhage?
A. Acute upper GI C. Upper or lower GI
B. Chronic upper GI D. Lower GI
2. Which of the following conditions is/are the most common causes of upper GI bleed?
A. Gastric ulcers C. Intestinal diverticular disease
B. Intestinal ulcers D. All of the above
3. A patient is admitted with a small pouch extending from the duodenum. The coder will
probably report category
A. 562.01—diverticulitis. C. 532.30—duodenal ulcer.
B. 562.00—diverticulosis. D. 531.30—acute gastric ulcer.
4. When minor adhesions are lysed as part of another procedure, how should you code the lysis
A. As an additional procedure B. As an incision
C. Don’t code the lysis of adhesions. D. Depends on the approach used
5. How should the presence of hematuria after a urinary tract procedure or prostatectomy
D. It shouldn’t be coded unless directed by the physician.
6. When a patient has both hypertension and renal disease, a relationship is presumed and
coded as one code together except in the case of
A. acute renal failure. C. renal disease with heart disease.
B. chronic renal failure. D. acute renal disease.
7. Which of the following factors most likely determines the appropriate procedure code
assignment for prostatectomies?
A. The approach C. The age of the patient
B. The case-mix index D. The presence of secondary diseases
8. A sacral decubitus ulcer with gangrene is coded and sequenced (if applicable) as codes
A. 707.03. C. 785.4.
B. 707.03, 785.4. D. 785.4, 707.03.
9. How many codes should be assigned for cellulitis as a complication of chronic skin ulcers?
A. One B. Two
C. Three D. Unsure, need to query physician
10. Any skin debridement performed by a physician should be coded to which of the following
A. 86.22 B. 86.27
C. 86.28 D. Need more information; must query physician for type of debridement used
1. When coding back disorders, which of the following conditions should always be considered for
inclusion in the code?
A. Degeneration C. Herniation
B. Myelopathy D. Arthritis
2. Laminectomy when performed with excision of herniated disc shouldn’t be coded separately
because this procedure is
A. a closure and inherent in the code.
B. an operative approach and inherent in the code.
C. an invasive surgical procedure.
D. never covered by third-party payers.
3. A code such as 733.13 can be assigned as principal diagnosis only when
A. the physician lists it first on the admission sheet with no other conditions.
B. there’s no underlying condition that’s being treated.
C. there’s an underlying condition that’s coded as secondary.
D. it has been ruled out as the secondary diagnosis.
4. Which of the following is the correct coding and sequencing—if applicable—for bilateral total
A. 81.51 C. 81.51, 81.53
B. 81.5 D. 81.51, 81.51
5. Codes from Chapter 11 refer to codes for
A. the mother only. C. the baby only.
B. the mother and baby. D. pregnancy conditions only.
6. The only circumstance for which code V27 can be assigned is on the
A. newborn’s record for birth in the hospital during the current episode of care.
B. newborn’s record to indicate birth on subsequent episodes of care.
C. mother’s record for delivery in hospital during current episode of care.
D. mother’s record to indicate delivery on subsequent episodes of care.
7. Which of the following scenarios would be assigned the code for normal delivery on the
A. Live birth, full term, cephalic presentation with episiotomy repair
B. Live birth, full term, cephalic presentation, postpartum breast abscess
C. Live birth, full term, breech presentation, rotated by version before delivery
D. Live birth, full term, vertex presentation, low forceps
8. A scenario in which categories V30–V39 are assigned is once, as the __________ diagnosis
to the __________ record at the time of birth.
A. principal, newborn C. secondary, newborn
B. principal, maternal D. secondary, maternal
9. A valid documentation for codes 764 or 765 would be physician documentation stating
A. gestational age as 35 weeks. C. low birth weight for 37 weeks.
B. fetal growth retardation. D. prematurity.
10. Which of the following are all category codes that could be assigned for acute-care hospitals?
A. V20, V29, V37 C. V27, V29, V30
B. V27, V29, V33 D. V33, V37, V39
ICD-9-CM Hospital Inpatient Coding
1. A patient is admitted to undergo chemotherapy for cancer of
the sigmoid colon that was previously treated with resection.
Which code is sequenced first?
A. 153.3 C. V58.1
B. 153.9 D. V10
2. A patient was admitted to the hospital for chest pain due to
tachycardia. While in the hospital, the patient was also treated
for type 1 diabetes. Upon further review, the coder noted that
the documentation and EKG didn’t provide further evidence
of the type of tachycardia or underlying cardiac condition(s).
What should the coder report as the principal diagnosis?
A. Chest pain B. Tachycardia, NOS
C. Insulin-dependent diabetes mellitus D. Cardiac disease, NOS
3. Dr. Smith recorded the following diagnoses on the patient’s discharge sheet:
gastrointestinal bleeding due to acute gastritis and angiodysplasia. The principal
diagnosis is coded as
A. GI bleeding.
B. acute gastritis.
D. either acute gastritis or angiodysplasia.
4. A patient was admitted with extreme fatigue and lethargy. Upon discharge, the
physician documents: fatigue due to either depression or hypothyroidism. Which
of the following are correct codes and sequencing for the scenario?
A. 780.79, 311, 244.9 C. 249.9, 311
B. 311, 249.9, 789.79 D. 789.79
5. Of the following, which code would take precedence over the other?
A. 072.0 over 033.0 C. 486 over 480
B. 595.0 over 131.09 D. 112.2 over 599.0
6. Upon discharge, the physician documents the following on the patient’s discharge
sheet: ?HIV infection. As the inpatient coder, your next step should be to
A. code the HIV infection as if it exists (according to UHDDS guidelines) and report it
as the principal diagnosis.
B. review the UHDDS guidelines for assigning possible HIV infection codes versus
C. query the physician and request that the statement be amended with a positive
(or negative) confirmation of the HIV infection.
D. wait to code the patient’s record until a positive finding on the serology report
confirms the HIV diagnosis.
7. For which of the following scenarios would it be appropriate to query the physician for
more information before coding and/or sequencing?
A. A patient was admitted with severe abdominal pain. At discharge, the physician
documents: abdominal pain due to either hiatal hernia or diverticula.
B. A patient was admitted with congestive heart failure (treated with IV furosemide)
and unstable angina (treated with nitrates).
C. A patient has low potassium levels noted on the laboratory report (treated with
orally administered potassium).
D. A patient is admitted with dysuria with no cause found.
8. Which of the following statements is true?
A. A patient has diabetes and an ulcer. Code the ulcer as diabetic.
B. A pregnant patient has diabetes. Code diabetes as complicating the pregnancy.
C. A patient has diabetes and cardiomyopathy. Code the cardiomyopathy as a diabetic
D. A patient has diabetes and cataracts. Code diabetic cataracts.
9. A patient was admitted for metastatic carcinoma from the breast to several lymph
node sites. Two years ago she had a double mastectomy. Which of the following is the
correct code assignment for this case?
A. 196.8, V10.3 C. 196.8, 174.9, 85.42
B. 174.9, 196.8 D. 196.8, 174.9, V10.3
10. One of the secondary diagnoses listed on the patient’s discharge sheet is seizures. As
a coder, your next step is probably
A. coding seizures to 780.39.
B. coding seizures to 345.
C. not reporting the code because it’s a symptom.
D. querying the physician for more information/clarification.
11. A patient was discharged with the diagnosis of acute bronchitis with chronic obstructive
asthma. Which of the following is the correct coding and sequencing (if applicable) for
A. 493.21 C. 466.0, 493.21
B. 493.21, 496 D. 493.91
12. Code 780.2 can be listed as principal diagnosis in which of the following cases?
A. For an outpatient encounter when the cause has been determined
B. For an inpatient encounter when the cause hasn’t been determined
C. When it’s listed with a contrasting diagnosis
D. It can never be listed as principal diagnosis.
13. Which of the following codes should not be listed as principal diagnosis?
A. 784.7 C. E812.0
B. V30.00 D. 307.81
14. Choose the correct code and sequencing for the following scenario: Reduction of right
humerus fracture with cast.
A. 79.00 C. 79.00, 93.53
B. 79.01 D. 79.01, 93.53
15. Read the following excerpt from medical record documentation and determine the
correct code(s) for coding. The physician writes: “…noted burn on the arm skin with
redness. Patient complained of tenderness to the touch.”
A. 943.01 C. 943.21
B. 943.10 D. 943.30
16. A patient was admitted in a coma from intentionally ingesting an entire bottle of
sedatives. Which of the following is the correct coding and sequencing assignment?
A. 780.01, 967.8 C. 967.8, E950.2
B. 780.01, 967.8, E950.2 D. 967.8, 780.01, E950.2
17. Which of the following situations would allow the assigning of a V code for a principal
A. Mother admitted for birth of infant, no complications
B. Patient admitted for dialysis
C. Patient admitted for metastatic breast cancer with a history of ovarian cancer
D. Patient admitted for poisoning has a history of alcoholism
18. A patient was admitted for nausea and vomiting due to gastroenteritis. Which of the
following is the correct code reporting and sequencing?
A. 787.01, 787.02, 558.9 C. 558.9, 787.01
B. 787.02, 787.03, 558.9 D. 558.9
19. A physician lists positive findings on a purified protein derivative (PPD) test as a
secondary diagnosis on the patient’s discharge sheet. How should this listing be coded?
D. This listing shouldn’t be coded.
20. A physician lists urosepsis as a secondary diagnosis on a patient’s discharge sheet.
How would you code this diagnosis?
A. Code it to 790.7. C. Code it to 599.0.
B. Code it to 038.9. D. Code 599.0, 038.9.
21. A patient is admitted for metastatic adenocarcinoma of the sacrum from the prostate.
A prostatectomy was performed 11 months ago. Which of the following should be
reported as the principal diagnosis for this patient?
A. V10 C. 198.5
B. 185 D. 170.6
22. A patient was discharged with a diagnosis of diabetes with nephropathy and chronic
renal failure. How many codes would be reported for this patient?
D. Need more information on the type of diabetes
23. If the physician describes the patient as presently in a manic phase, but has
experienced depression in the past, this condition may be coded as
A. 296.4X C. 296.6X
B. 296.5X D. Need more information
24. Codes 331.9, 332.0, are conditions affecting the
A. central nervous system. C. gastrointestinal system.
B. peripheral nervous system. D. cardiovascular system.
25. A patient was admitted with an acute exacerbation of chronic obstructive bronchitis
and found to be in respiratory failure. Which of the following is the correct coding and
sequencing for this case?
A. 518.81, 491.21 C. 518.81, 496
B. 491.21, 518.81 D. 493.91, 496, 518.81
1. Which of the following is an example of a HCPCS Level I code?
A. 81.52 C. 96410
B. 011.60 D. Q0084
2. Hospital inpatient procedures and interventions are reported using
A. Volume 3 of ICD-9-CM.
B. Volume 3 of ICD-9-CM and HCPCS Level I.
C. HCPCS Level I.
D. HCPCS Level II.
3. For outpatient procedures, the CMS requires reporting codes using
A. Volume 3 of ICD-9-CM.
B. Volume 3 of ICD-9-CM and HCPCS Level I.
C. HCPCS Level I.
D. HCPCS Level II.
4. The UHDDS definition for principal diagnosis applies to
A. inpatients. C. inpatients and outpatients.
B. outpatients. D. all coded information.
5. Which rule is correct when an outpatient is seen for chemotherapy?
A. List first the diagnosis, followed by the chemotherapy V code.
B. List first the chemotherapy V code, followed by the diagnoses.
C. List only the V code for chemotherapy.
D. List only the code for the diagnosis.
6. Review the following ICD-9-CM coding instruction excerpt: Cardiotomy and pericardiotomy—
Code also cardiopulmonary bypass [extracorporeal circulation][heart-lung machine] (39.61)
According to this excerpt, how many ICD-9-CM procedure codes should be assigned?
A. 0 C. 2
B. 1 D. Need more information
7. For an outpatient with gallstones who had a laparoscopic cholecystectomy performed, how
many codes are required for reporting?
A. 1 C. 3
B. 2 D. 4
8. What happens when an inpatient procedure is canceled after a patient has been admitted?
A. Code V64.X as the secondary diagnosis with no procedure code assigned
B. Code V64.X as the principal diagnosis with no procedure code assigned
C. Code V64.X as secondary diagnosis with the procedure coded as completed
D. Code V64.X as principal diagnosis with the procedure coded as completed
9. If you were looking for corneal reconstruction in the CPT Index, what term gets you to the
A. Cornea C. Revision
B. Eye D. Reconstruction
1. Which of the following is the correct set of coding guidelines that physicians are
required to report?
A. ICD-9-CM codes for diagnoses and HCPCS codes for procedures and services
B. ICD-9-CM codes for diagnoses, HCPCS and ICD-9-CM codes for procedures
C. Only HCPCS and ICD-9-CM procedure codes
D. Only HCPCS procedure and service codes
2. In a physician’s office, coding and billing is done for which of the following categories?
A. Only physician office services
B. Only services the physician perform in hospitals
C. Only services performed in outpatient centers
D. All physician services performed, no matter where the service occurred
3. A significant portion of the services that physicians provide are reported by _______ codes.
A. E C. E/M
B. V D. Q/T
4. Which of the following codes requires the use of modifiers?
A. ICD-9-CM procedures C. ICD-9-CM diagnosis codes
B. HCPCS D. Varies according to the setting
5. Using two or more codes when one code would be sufficient to represent all services is an
A. unbundling. C. “Code Also.”
B. bundling. D. inclusion.
6. A Medicare patient had a benign lesion measuring 0.5 cm removed from his back at his
physician’s office. Which of the following codes is correct?
A. 17000 C. 11600-57
B. 11400-57 D. 11400
7. What is the proper modifier to use for referring to services performed by a physician who
repaired a broken leg and a broken arm at the same operative session?
B. -59 D. -77
8. Which code is appropriate for a radiologist’s report on a 23-year-old patient who had an X-ray
of the left and right forearms?
A. 73090-50 C. 73090-LT, 73090-RT
B. 73221 D. 73090, 73090-59
9. How does a physician ensure that each laboratory test performed in his/her office is
A. Assign a separate code for each test
B. Report the appropriate panel code for the tests.
C. Make sure that each test is documented
D. Only order and report medically necessary tests
10. What is the correct code for IV infusion for therapy/diagnosis, administered by physician or
under direct supervision of physician—up to one hour?
A. 96365 C. 90782
B. 90779 D. 90783
1. Which of the following would be coded within the HCPCS Level II series code range of
A. Ambulance ride to an emergency department
B. Artificial kidney machine
C. Commode chair
D. Sterile needle
2. HCPCS Level II drugs are listed mainly in which of the following coding sections?
A. A codes C. J codes
B. F codes D. Q codes
3. HCPCS Level II modifiers may be used with
A. Level I or Level II HCPCS codes. C. CPT codes only.
B. Level I, II, or III HCPCS codes. D. CPT and ICD-9-CM procedure codes.
4. Services like transportation and wheelchairs are reported under
A. ICD-9-CM. C. HCPCS Level I codes.
B. CPT. D. HCPCS Level II E codes.
5. An ambulance picks up a patient at her sister’s house. Which of the following is the correct
modifier for this type of service?
A. -H C. -R
B. -P D. -RH
6. The code A4642 is classified under which of the following categories?
A. Drug C. Ambulance service
B. Supply D. Durable medical equipment
7. What is the corresponding HCPCS Level II code for HCPCS Level I code 96360?
A. S9373 C. S9376
B. S9374 D. S9375
8. In what category do you code administration of Procrit if not identified by Levels I or II?
A. A codes C. J codes
B. G codes D. Q codes
9. Which of the following is the HCPCS Level II code for a single-use chemotherapy pump?
A. E0781 C. A9270
B. G0361 D. 99070
10. Which of the following is a true statement about HCPCS Level II supplies?
A. They’re often included within the procedure code.
B. They’re always coded separately.
C. They’re covered under “unlisted” procedure codes.
D. They’re covered under HCPCS Level I.
Code only the HCPCS Level II code or codes (plus modifiers, if applicable) for
each example. Use the lists that you downloaded from the CMS.
1. Physician’s professional component of interpreting an abnormal Pap smear
2. Five surgical team members meet with the patient to determine a treatment course
3. Annual flu vaccine at a local grocery store
4. Infusion, albumin (human), 5%, 50 mL
5. Gastrostomy tubing
6. Heavy-duty folding walker with a seat and wheels
7. Psychiatrist screens a patient to determine eligibility for an alcohol and drug program
8. Transportation of a portable EKG to a physician’s office for a patient
9. Anterior chamber intraocular lens
10. TLSO corset front
Part 1—Multiple Choice
1. The HCPCS Level I codes used by all specialties no matter the location are included in
code category ranges
2. A patient was seen due to continuing congestion and sniffling. She complained of
pressure when breathing through her nose. The physician documented a diagnosis of
edema of nasal mucosa likely due to allergic rhinitis and performed rhinoscopy. The
coder codes 478.25, 31231, 21.21. This patient was most likely seen in what setting?
B. Outpatient surgical unit
C. Physician office
D. Need more information
3. In which of the following scenarios is it appropriate to assign a HCPCS Level II code in
addition to the CPT code?
A. Four extra surgical trays are used.
B. A surgery is repeated due to special circumstances.
C. A patient is transferred to a nursing home after surgery.
D. A physician performs an examination and realizes the patient needs IV antibiotics.
4. Code 27709 can be interpreted as
A. tibia and fibula.
B. osteotomy, tibia.
C. osteotomy, tibia and fibula.
D. osteotomy, fibula.
5. A physician excised a 3.5 cm benign lesion from an outpatient’s scalp. Code:
6. Which of the following scenarios would require the assignment of both a HCPCS Level I
and Level II code?
A. Injection of Botulinum toxin type A, per unit
B. Appendectomy with anesthesia
C. Review of HIV test
D. Hernia repair with mesh
7. Which indicates Diagnostic Radiopharmaceutical Imaging Agent NOC?
8. Adenosine 3mg IV is drawn from a 6 mg ampule and administered to convert a
supraventricular arrhythmia. How should this be reported?
9. Which of the following is the correct modifier to use when 97112 and 97116 are
10. HCPCS Level II codes are developed and maintained by
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