Instructions: Print this exam worksheet. Return to the course page using the link below. Read the course material. Enter your answers on this worksheet. Return to the course page and click the link 'Take Test.' Transfer your answers.

https://www.quantumunitsed.com/go/781

Quantum Units Education®

ICD-10-CM Coding and Reporting Guidelines

Section I: Conventions, general coding guidelines and chapter specific guidelines - A: Conventions for the ICD-10-CM

1. All categories are _____ characters.

A. 3

B. 4

C. 5

D. 7


2. A code that has an applicable 7th character is considered invalid without the 7th character.

A. True

B. False


3. For reporting purposes, _____ are permissible.

A. Categories

B. Subcategories

C. Codes

D. Codes, categories, and subcategories are all permissible for reporting purposes


4. If a code that requires a 7th character is not 6 characters, a placeholder X must be used to fill in the empty characters.

A. True

B. False


5. An exception to the Excludes1 definition is the circumstances when the two conditions are related to each other.

A. True

B. False


6. All of the following pertain to “in diseases classified elsewhere” manifestation codes, except for:

A. They must be used in conjunction with an underlying condition code.

B. They should be used as first-listed or principal diagnosis codes.

C. They must be listed following the underlying condition.

D. The code title indicates that it is a manifestation code.


7. In the Alphabetic Index both conditions are listed together with the manifestation code first followed by the etiology code in brackets.  The code in brackets is always to be sequenced second.

A. True

B. False


8. It is not necessary to follow the “see also” note when the original main term provides the necessary code.

A. True

B. False


Section I: Conventions, general coding guidelines and chapter specific guidelines - B: General Coding Guidelines

9. Selection of the full code, including laterality and any applicable 7th character can be done in:

A. The Tabular List only

B. The Alphabetic Index only

C. Both the Tabular List and the Alphabetic Index

D. Neither the Tabular List nor the Alphabetic Index


10. When there is a “code first” note and an underlying condition is present, the underlying condition should be sequenced first, if known.

A. True

B. False


11. If the same condition is described as both acute (subacute) and chronic, and separate subentries exist in the Alphabetic Index at the same indentation level, code both and sequence the chronic code first.

A. True

B. False


12. Which of the following is true for sequela codes?

A. A sequela code must be used within one year of the termination of the acute phase of an illness or injury.

B. Coding of sequela generally requires two codes sequenced in the following order: the condition or nature of the sequela is sequenced first and the sequela code is sequenced second.

C. The code for the acute phase of an illness or injury that led to the sequela is always used with a code for the late effect.

D. There are no exceptions to the coding guidelines for sequela coding.


13. If no bilateral code is provided and the condition is bilateral, assign separate codes for both the left and right side.

A. True

B. False


14. Which of the following should only be reported as a secondary diagnosis?

A. BMI

B. Coma scale

C. Categories Z55 - Z65

D. The BMI, coma scale, NIHSS codes, and categories Z55 - Z65 should only be reported as secondary diagnoses


15. All conditions that occur during or following medical care or surgery are classified as complications.

A. True

B. False


16. Each healthcare encounter should be coded to the level of certainty known for that encounter.

A. True

B. False


Section I: Conventions, general coding guidelines and chapter specific guidelines - C: Chapter-Specific Coding Guidelines

17. Z21, Asymptomatic human immunodeficiency virus [HIV] infection status, is to be applied when:

A. The term “AIDS” is used.

B. The patient is treated for HIV-related illness.

C. The patient is described as having any condition(s) resulting from his/her HIV positive status.

D. The patient without any documentation of symptoms is listed as being “HIV positive,” “known HIV,” “HIV test positive,” or similar terminology.


18. It is necessary to identify all infections documented as antibiotic resistant.

A. True

B. False


19. The term urosepsis is to be considered synonymous with sepsis.

A. True

B. False


20. The code for septic shock cannot be assigned as a principal diagnosis.

A. True

B. False


21. When both the associated non-infectious condition and the infection meet the definition of principal diagnosis:

A. The associated non-infectious condition should always be assigned as principal diagnosis.

B. The infection should always be assigned as principal diagnosis.

C. Either may be assigned as principal diagnosis.

D. A combination code must be applied as neither can be assigned as principal diagnosis.


22. Colonization means:

A. MSSA or MSRA is present on or in the body without necessarily causing illness.

B. Illness must be being caused by the presence of MSSA or MSRA on or in the body.

C. It is indicative of a disease process.

D. It is the cause of a specific condition the patient may have.


23. The only exception of designating the malignant neoplasm as the principal diagnosis when the treatment is directed at the malignancy is:

A. If a patient admission/encounter is solely for the administration of chemotherapy, immunotherapy, or external beam radiation therapy.

B. Cataclysmic events, such as a hurricane.

C. Child and adult abuse.

D. Terrorism.


24. When a patient is admitted because of a primary neoplasm with metastasis and treatment is directed toward the secondary site only, the primary malignancy is designed as the principal diagnosis.

A. True

B. False


25. The anemia code should be sequenced first, except when:

A. The admission / encounter is for management of an anemia associated with an adverse effect of the admission of chemotherapy or immunotherapy and the only treatment is for the anemia.

B. The admission / encounter is for management of an anemia associated with an adverse effect of radiotherapy.

C. The admission / encounter is for management of an anemia associated with a malignancy, and the treatment is only for anemia.

D. The anemia code should aways follow the principal diagnosis.


26. When an encounter is for management of a complication associated with a neoplasm and the treatment is only for the complication, the complication is coded first, followed by the appropriate code(s) for the neoplasm.  The exception to this guideline is:

A. Dehydration

B. Anemia

C. MSSA or MSRA

D. Pathologic fracture


27. Subcategories Z85.0 - Z85.7 should only be assigned for:

A. The former site of a primary malignancy.

B. The site of a secondary malignancy.

C. The former site(s) of either a primary or secondary malignancy included in the subcategory.

D. Subcategories Z85.0 - Z85.7 should never be assigned to malignancies.


28. If the type of diabetes mellitus is not documented in the medical record, the default is:

A. Z79.4, Secondary diabetes mellitus and use of insulin or oral hypoglycemic drugs

B. O24.4, Gestational diabetes

C. E08.-, Type 1 diabetes mellitus

D. E11.-, Type 2 diabetes mellitus


29. When the provider documentation refers to both abuse and dependence of the same substance, assign only the code for abuse.

A. True

B. False


30. Which of the following would receive the code F68.A, “factitious disorder imposed on another” or “factitious disorder by proxy”?

A. The victim

B. The perpetrator

C. Both the victim and the perpetrator

D. Code F68.A should not be used under these circumstances


31. Routine or expected postoperative pain immediately after surgery should not be coded.

A. True

B. False


32. Assign as many codes from category H40, Glaucoma, as needed to identify:

A. The type of glaucoma

B. The affected eye

C. The glaucoma stage

D. As many codes from category H40 as needed should be assigned to identify the type of glaucoma, the affected eye, and the glaucoma stage


33. The seventh character “0” is used for glaucomas whose stage cannot be clinically determined.

A. True

B. False


34. For hypertension and conditions not specifically linked by relational terms such as “with,” “associated with,” or “due to” in the classification, provider documentation must link the conditions in order to code them as related.

A. True

B. False


35. If a patient has hypertension, heart disease, and chronic kidney disease, _____ should be used.

A. A code from I11

B. A code from I12

C. A code from I13

D. Individual codes for hypertension, heart disease, and chronic kidney disease


36. If a patient with coronary artery disease is admitted due to an acute myocardial infarction (AMI), the AMI should be sequenced before the coronary artery disease.

A. True

B. False


37. If a type 1 STEMI converts to NSTEMI due to thrombolytic therapy, assign the NSTEMI code.

A. True

B. False


38. A code from category I22, Subsequent ST elevation (STEMI) and non-ST elevation (NSTEMI) myocardial infarction, is to be used when a patient who has suffered a type 1 or unspecified AMI has a new AMI within the _____ time frame of the initial AMI.

A. 7 day

B. 2 week

C. 4 week

D. 3 month


39. The term “confirmation” in the context of influenza requires documentation of positive laboratory testing specific for avian or other novel influenza A or other identified influenza virus.

A. True

B. False


40. Ventilator associated Pneumonia requires an additional code to be assigned from categories J12 - J18 to identify the type of pneumonia.

A. True

B. False


41. If a patient is admitted to an inpatient hospital with a pressure ulcer at one stage and it progresses to a higher stage, which code should be assigned?

A. The code for the site and stage of the ulcer on admission.

B. The code for the site and the higher stage reported during the stay.

C. Two separate codes should be assigned: one for the site and stage of the ulcer on admission and a second code for the same ulcer site and the higher stage reported during the stay.

D. Pressure ulcers that progress to a higher stage should be assigned the code for unspecified stage.


42. For certain conditions, the bone may be affected at the upper or lower end.  When the portion of the bone affected is at the joint, the site designation will be the:

A. Joint

B. Bone

C. Both joint and bone codes should be assigned

D. The code assigned will be for the condition present at the time of admission, not the site affected


43. When coding for pathologic fractures, the 7th character “A” is for use:

A. As long as the patient is receiving active treatment for the fracture.

B. If the provider is seeing the patient for the first time.

C. Of encounters after the patient has completed active treatment for the fracture and is receiving routine care for the fracture during the health or recovery phase.

D. For subsequent encounters for treatment of problems associated with the healing, such as malunions, nonunions, and sequelae.


44. The site codes under category M80, Osteoporosis with current pathological fracture, identify the site of:

A. The osteoporosis

B. The fracture

C. Both the osteoporosis and the fracture

D. All historical fractures


45. Chapter 15 codes are to be used:

A. Only on the maternal record

B. Only on the newborn record

C. On both the maternal and newborn records

D. On neither the maternal nor newborn records


46. In instances when a patient is admitted to a hospital for complications of pregnancy during one trimester and remains in the hospital into a subsequent trimester, the trimester character for the antepartum complication code should be assigned on the basis of the trimester of the discharge.

A. True

B. False


47. Assign 7th character “0” for Fetus Identification:

A. For single gestations.

B. When the documentation in the record is insufficient to determine the fetus affected and it is not possible to obtain clarification.

C. When it is not possible to clinically determine which fetus is affected.

D. When identifying the fetus for which the complication code applies, the 7th character “0” should be assigned for single gestations, when the documentation in the record is insufficient to determine the fetus affected and it is not possible to obtain clarification, or when it is not possible to clinically determine which fetus is affected.


48. A code from category Z37, Outcomes of delivery, should be included:

A. On the newborn record.

B. On every maternal recored when a delivery has occurred.

C. On subsequent maternal records after a delivery.

D. A code from category Z37, Outcomes of delivery, should be included on the newborn record, every maternal recored when a delivery has occurred, and on subsequent maternal records after a delivery.


49. It is acceptable to use codes specifically for the puerperium with codes complicating pregnancy and childbirth if a condition arises postpartum during the delivery encounter.

A. True

B. False


50. If a patient with gestational diabetes is treated with both diet and insulin, the code for _____ is required under the subcategory O24.4.

A. Controlled by oral hypoglycemic drugs

B. Diet controlled

C. Insulin-controlled

D. Both diet and insulin controlled


51. Which code should be used for puerperal sepsis?

A. A code from category A40, Streptococcal sepsis

B. A code from category A41, Other sepsis

C. Neither A40 nor A41 should be used

D. Either A40 or A41 can be used


52. All clinically significant conditions noted on routine newborn examination should be coded.  A condition is clinically significant if it requires:

A. Therapeutic treatment

B. Diagnostic procedures

C. Extended length of hospital stay

D. Clinical evaluation, therapeutic treatment, diagnostic procedures, extended length of hospital stay, increased nursing care and/or monitoring, and having implications for future health care needs are all clinically significant conditions


53. Assign a code from category Z05, Observation and evaluation of newborns and infants for suspected conditions ruled out, when the patient has identified signs or symptoms of a suspected problem.

A. True

B. False


54. Assign code R40.24, Glasgow coma scale, total score:

A. When only the total score is documented in the medical record and not the individual score(s).

B. For patients with a medically induced coma.

C. For sedated patients.

D. Code R40.24 should only be used for patients with medically induced comas or who are sedated.


55. Code R99, Ill-defined and unknown cause of mortality:

A. Represents the discharge disposition of death.

B. Is for use when a patient who has already died is brought into an emergency department or other healthcare facility and is pronounced dead upon arrival.

C. Has a 7th character requirement.

D. Refers to unknown complications leading to death after being admitted to an emergency department or other healthcare facility.


56. Fractures not indicated as open or closed and/or displaced or not displaced, should respectively be coded:

A. Open and/or displaced

B. Open and/or not displaced

C. Closed and/or displaced

D. Closed and/or not displaced


57. The ICD-10-CM burn codes are for burns that come from all of the following, except:

A. Fire

B. A hot appliance

C. Electricity

D. Sunburns


58. Necrosis of burned skin should be coded as a non-healed burn.

A. True

B. False


59. It is advisable to use category T31 as an additional code for reporting purposes when there is mention of a third-degree burn involving _____% or more of the body surface.

A. 9

B. 18

C. 20

D. 50


60. If the intent of a poisoning is unknown or unspecified, code the intent as undetermined intent.

A. True

B. False


61. When a reaction results from the interaction of a drug(s) and alcohol, this would be classified as poisoning.

A. True

B. False


62. The external causes of morbidity codes should never be sequenced as the first-listed or principal diagnosis.

A. True

B. False


63. External cause codes for terrorism events take priority over all other external cause codes except:

A. Cataclysmic events

B. Transport accidents

C. Self-harm

D. Child and adult abuse


64. The external cause status codes are not applicable to:

A. Poisonings

B. Adverse effects

C. Misadventures

D. The external cause status codes are not applicable to poisonings, adverse effects, misadventures or late effects


65. All of the following apply to status codes, except for:

A. Status codes indicate that a patient is either a carrier of a disease or has the sequelae or residual of a past disease or condition.

B. A status code is the same as a history code.

C. A status code is informative, because the status may affect the course of treatment and its outcomes.

D. Status codes include such things as the presence of prosthetics or mechanical devices resulting from past treatment.


66. Genetic carrier indicates that a person has a gene that increases the risk of that person developing the disease.

A. True

B. False


67. Do not assign BMI codes:

A. During pregnancy

B. If the person is slightly overweight

C. If the person is morbidly obese

D. When someone is a bodybuilder


68. The long-term (current) drug therapy code is for use of medications for detoxification or maintenance programs to prevent withdrawal symptoms in patients with drug dependence.

A. True

B. False


69. History codes are acceptable on any medical record regardless of the reason for visit.

A. True

B. False


70. The testing of a person to rule out or confirm a suspected diagnosis because the patient has some sign or symptom is:

A. A diagnostic examination

B. A screening

C. An assessment

D. A treatment


71. Aftercare visit codes cover all of the following, except:

A. Situations when the initial treatment of a disease has been performed and the patient requires continued care during the healing or recovery phase.

B. For treatment directed at a current, acute disease.

C. For the long-term consequences of the disease.

D. Aftercare visit codes cover situations when the initial treatment of a disease has been performed and the patient requires continued care during the healing or recovery phase, for treatment directed at a current, acute disease, and for the long-term consequences of the disease.


72. Codes in category Z52, Donors of organs and tissues, are used for:

A. Living individuals who are donating blood or other body tissues.

B. Individuals doing self-donations.

C. Cadaveric donations.

D. Codes in category Z52, Donors of organs and tissues, are used for living individuals who are donating blood or other body tissues, individuals doing self-donations, and cadaveric donations.


73. Codes in category Z3A, Weeks of gestation, may be assigned for:

A. Pregnancies with abortive outcomes

B. Elective termination of pregnancy

C. Postpartum conditions

D. Additional information about the pregnancy


74. The Z codes allow for:

A. Examinations for diagnosis of a suspected condition.

B. Examinations for treatment purposes.

C. The description of encounters for routine examinations, such as, a general check-up, or, examinations for administrative purposes, such as, a pre-employment physical.

D. The Z codes allow for examinations for diagnosis of a suspected condition or treatment and for the description of encounters for routine examinations, such as, a general check-up, or, examinations for administrative purposes, such as, a pre-employment physical.


Section II: Selection of Principal Diagnosis

75. In the instance when two or more diagnoses equally meet the criteria for principal diagnosis as determined by the circumstances of admission, diagnostic workup and/or therapy provided, and the Alphabetic Index, Tabular List, or another coding guidelines does not provide sequencing direction, any one of the diagnoses may be sequenced first.

A. True

B. False


76. When a patient receives surgery in the hospital’s outpatient surgery department and is subsequently admitted for continuing inpatient care at the same hospital, which of the following guidelines should be followed in selecting the principal diagnosis for the inpatient admission?

A. If the reason for the inpatient admission is a complication, assign the complication as the principal diagnosis.

B. If no complication, or other condition, is documented as the reason for the inpatient admission, assign the reason for the outpatient surgery as the principal diagnosis.

C. If the reason for the inpatient admission is another condition unrelated to the surgery, assign the unrelated condition as the principal diagnosis.

D. If the reason for the inpatient admission is a complication, assign the complication as the principal diagnosis; If no complication, or other condition, is documented as the reason for the inpatient admission, assign the reason for the outpatient surgery as the principal diagnosis.; If the reason for the inpatient admission is another condition unrelated to the surgery, assign the unrelated condition as the principal diagnosis.


Section IV: Diagnostic Coding and Reporting Guidelines for Outpatient Services

77. The most critical rule involves beginning the search for the correct code assignment through the Tabular List.  Never begin searching initially in the Alphabetic Index as this will lead to coding errors.

A. True

B. False


78. When coding for uncertain diagnoses, code all diagnoses, including those documented as “probable,” “suspected,” “questionable,” and “working diagnosis.”

A. True

B. False


79. For patients receiving therapeutic services only, the diagnosis, condition, problem, or other reason for the encounter / visit should be sequenced first, except when the primary reason for the admission / encounter is:

A. For a check-up during pregnancy

B. Chemotherapy or radiation therapy

C. Due to a cataclysmic event

D. Involving terrorism


Appendix I

80. The determining factor for POA assignment of obstetrical conditions is:

A. Whether the pregnancy complication or obstetrical condition described by the code was present at the time of admission or not.

B. Whether or not the patient delivers during the current hospitalization.

C. Whether or not fetal distress develops after admission.

D. Whether or not there was postpartum hemorrhage that occurred during the current hospitalization.


Copyright © 2019 Quantum Units Education

Visit us at QuantumUnitsEd.com!