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Question 1: What is the term for a prefix that means "without"? A) Anti- B) Hyper- C) Macro- D) Tele- Answer: A Explanation: The prefix "anti-" means "against" or "without," as seen in antacid or antibiotic. Question 2: Which of the following is a root word for "blood"? A) Hemo- B) Cardi- C) Pulmo- D) Nephro- Answer: A Explanation: The root word "hemo-" refers to blood, as seen in hemoglobin or hemophilia. Question 3: What is the term for a suffix that indicates a disease or disorder? A) - itis B) - osis C) - oma D) - algia Answer: A Explanation: The suffix "-itis" indicates inflammation or a disease, as seen in arthritis or bronchitis. Question 4: Which of the following is a type of pharmacological agent used to treat hypertension? A) Beta blockers
B) Diuretics C) ACE inhibitors D) All of the above Answer: D Explanation: Beta blockers, diuretics, and ACE inhibitors are all types of pharmacological agents used to treat hypertension. Question 5: What is the ICD- 10 - CM code for a diagnosis of acute myocardial infarction (AMI)? A) I21. B) I21. C) I22. D) I23. Answer: A Explanation: The ICD- 10 - CM code I21.0 represents an AMI, also known as a heart attack. Question 6: Which of the following is a coding convention for ICD- 10 - CM? A) Use the highest level of specificity B) Use the lowest level of specificity C) Use alphanumeric codes only D) Use numeric codes only Answer: A Explanation: The ICD- 10 - CM coding convention requires using the highest level of specificity when assigning codes. Question 7: What is the term for a procedure code that represents a surgical intervention? A) CPT code
B) Radiology C) Pathology and Laboratory services D) All of the above Answer: D Explanation: Each medical specialty has its own unique coding requirements and guidelines. Coding Documentation and Querying Question 11: What is the term for a query that seeks clarification on a specific piece of documentation? A) Compliant query B) Non-leading query C) Open-ended query D) Closed-ended query Answer: B Explanation: A non-leading query seeks clarification on a specific piece of documentation without influencing the provider's response. Question 12: Which of the following is a principle of compliant and ethical physician querying? A) Use leading questions to guide the provider's response B) Use open-ended questions to gather more information C) Avoid asking questions that could influence the provider's response D) Ask questions in writing only Answer: C Explanation: Compliant and ethical querying involves avoiding questions that could influence the provider's response.
Question 13: What is the term for a document that contains essential elements required for specific service types and conditions? A) Medical record documentation B) Provider query response C) Coding guidelines manual D) Clinical guideline document Answer: A Explanation: Medical record documentation contains essential elements required for specific service types and conditions. Question 14: Which of the following is an example of insufficient documentation? A) Provider notes are complete and concise. B) Laboratory results are up-to-date. C) History and physical examination are documented. D) All of the above Answer: D Explanation: Insufficient documentation can occur when any of these elements are missing or incomplete. Question 15: What is the term for a document that outlines official guidelines for coding and reporting? A) Official Guidelines for Coding and Reporting (OGCR) B) CPT coding manual C) ICD- 10 - CM coding manual D) HCPCS Level II coding manual Answer: A Explanation: The OGCR outlines official guidelines for coding and reporting, including ICD- 10 - CM, ICD- 10 - PCS, CPT, and HCPCS Level II.
Explanation: CERP is a process used to identify and resolve coding discrepancies. Question 19: Which of the following is an example of a legal issue in coding? A) HIPAA compliance B) False Claims Act (FCA) C) Stark Law compliance D) All of the above Answer: D Explanation: HIPAA compliance, FCA, and Stark Law compliance are all examples of legal issues in coding. Question 20: What is the term for a type of reimbursement system used by managed care organizations? A) Fee-for-service (FFS) B) Capitation payment system C) Global payment system D) Bundle payment system Answer: B Explanation: Capitation payment systems are used by managed care organizations to reimburse healthcare providers. Information Technologies and Data Management Question 21: What is the term for a type of electronic health record (EHR)? A) Electronic medical record (EMR) B) Personal health record (PHR) C) Clinical data repository (CDR) D) Data warehouse
Answer: A Explanation: EMRs are electronic versions of paper-based medical records. Question 22: Which of the following is an example of encoding software? A) Computer Assisted Coding (CAC) B) Encoding software for clinical documentation improvement (CDI) C) Data extraction software for analytics (DESA) D) All of the above Answer: B Explanation: Encoding software for CDI involves encoding clinical documentation into standardized formats. Question 23: What is the term for a database that stores coded data? A) Data warehouse (DW) B) Data mart (DM) C) Clinical data repository (CDR) D) Electronic health record (EHR) Answer: A Explanation: Data warehouses store large volumes of coded data from various sources. Question 24: Which of the following is an example of data quality control measure? A) Reviewing coded data for accuracy and completeness. B) Conducting internal audits to ensure compliance with regulatory requirements. C) Implementing data validation checks to ensure data consistency. D) All of the above
Answer: A Explanation: The ICD- 10 - PCS tables are organized by body part and system, and procedures involving the heart are coded under the cardiovascular system table.
- In CPT coding, modifiers are used to: A) Denote a different procedure than the original code B) Provide additional information about the service or procedure C) Indicate a duplicate billing D) Replace the original CPT code Answer: B Explanation: Modifiers in CPT codes offer extra details about the performed service, such as laterality or unusual circumstances.
- Which HCPCS Level II code corresponds to a durable medical equipment prosthetic device? A) E B) E C) A D) C Answer: A Explanation: E0100 is an example of a HCPCS Level II code for a prosthetic device, specifically a crutch.
- When coding for Evaluation and Management (E/M) services, what factors influence the level of service? A) History, exam, and medical decision-making B) Duration of the visit only C) Number of procedures performed D) Patient's insurance type
Answer: A Explanation: E/M service levels are determined by history, examination, and medical decision-making complexity.
- Which of the following is an example of a "principal procedure" in inpatient coding? A) The most complex procedure performed during the admission B) The first procedure listed in the operative report C) The procedure most directly related to the principal diagnosis D) Any procedure performed on the patient Answer: C Explanation: The principal procedure is the main procedure that is directly related to the principal diagnosis and performed during the encounter.
- In ICD- 10 - CM coding, what does the "POA" indicator signify? A) Present on Admission B) Probable on Arrival C) Patient's Overall Assessment D) Procedure Ordered Annually Answer: A Explanation: POA indicates whether a condition was present at the time of inpatient admission.
- What is the primary purpose of the Official Guidelines for Coding and Reporting? A) To establish standardized coding practices B) To provide billing instructions only C) To dictate reimbursement policies D) To restrict access to coding manuals
D) Proper sequencing of diagnoses Answer: A Explanation: Denials often occur due to insufficient or unclear documentation supporting the assigned codes.
- Which of the following is an example of a compliant provider query? A) "Please clarify whether this was a new or recurrent infection." B) "The diagnosis is pneumonia; please confirm." C) "Did the patient have a stroke?" D) "The provider's note is incomplete." Answer: A Explanation: A compliant query seeks clarification without leading or influencing the provider’s response.
- Under HIPAA, what must be protected when handling coded health information? A) Patient privacy and confidentiality B) The provider’s personal details C) The hospital's financial data D) Public health records Answer: A Explanation: HIPAA mandates the safeguarding of patient health information to protect privacy and confidentiality.
- Which is an example of a typical internal audit objective in coding compliance? A) To identify coding errors and ensure adherence to guidelines B) To maximize reimbursement regardless of documentation C) To replace clinical documentation with coding notes
D) To eliminate the need for provider queries Answer: A Explanation: Internal audits aim to identify errors and improve compliance with coding standards and guidelines.
- Which coding guideline helps determine whether a diagnosis should be coded as "probable," "suspected," or "confirmed"? A) Confirmed diagnosis always takes precedence B) The guideline for "uncertain" diagnoses C) The documentation indicates the diagnosis status D) Coding is based on provider suspicion only Answer: C Explanation: Coding guidelines specify that diagnoses should be coded based on documentation indicating certainty, suspicion, or confirmation.
- What is the primary function of Computer Assisted Coding (CAC) software? A) To automate coding based on clinical documentation B) To replace coders entirely C) To generate billing statements only D) To store patient demographic data Answer: A Explanation: CAC software uses algorithms to assist in assigning codes based on clinical documentation.
- Which of the following is essential for ensuring data quality in coded health records? A) Complete and accurate documentation B) Coding without review C) Manual data entry only
D) The outcome of the procedure Answer: A Explanation: The approach character describes how the procedure was performed, such as open or percutaneous.
- In CPT coding, what is the purpose of the "unlisted procedure" code? A) To report procedures not specified by existing codes B) To indicate a canceled procedure C) To replace the standard code for a common procedure D) To denote a duplicate service Answer: A Explanation: Unlisted procedure codes are used when no specific code exists for the performed service.
- Which of the following is a common modifier used to indicate a bilateral procedure? A) - 51 B) - 50 C) - LT (Left) D) - RT (Right) Answer: C Explanation: Modifier - LT indicates a left-side procedure, often used for bilateral procedures.
- What is the primary goal of accurate coding in relation to reimbursement? A) To ensure appropriate payment for services rendered B) To maximize revenue regardless of documentation C) To avoid audits D) To simplify billing processes
Answer: A Explanation: Accurate coding ensures that providers are reimbursed appropriately based on documented services.
- Which coding system is primarily used for reporting services like immunizations and certain preventive services? A) ICD- 10 - CM B) CPT® C) HCPCS Level II D) ICD- 10 - PCS Answer: C Explanation: HCPCS Level II codes include immunizations and preventive services.
- When reviewing radiology reports for coding, what key information must be identified? A) Imaging modality and anatomic site B) Technical and professional components C) Findings and interpretations D) All of the above Answer: D Explanation: Accurate radiology coding depends on detailed information about modality, site, findings, and who performed the service.
- In a medical record, which component is MOST crucial for determining the correct principal diagnosis? A) Admission note B) Discharge summary C) Operative report
D) A canceled service Answer: A Explanation: A separate procedure is a minor service that can be billed independently, such as a small biopsy.
- When assigning ICD- 10 - CM codes, what does the term "combination code" refer to? A) A code that captures multiple diagnoses in one code B) A code that combines diagnosis and procedure C) A code used only for outpatient services D) A code that is used when documentation is incomplete Answer: A Explanation: Combination codes represent related diagnoses or conditions in a single code, streamlining coding.
- Which of the following is a key component of effective medical record abstraction? A) Selecting all documented diagnoses and procedures B) Ignoring ambiguous documentation C) Ensuring only primary diagnoses are captured D) Selecting diagnoses based on insurance coverage Answer: A Explanation: Effective abstraction involves capturing all relevant, supported diagnoses and procedures for accurate coding.
- In the context of outpatient coding, what does the term "medical necessity" refer to? A) Services that are appropriate and supported by medical documentation B) Services that maximize reimbursement C) Services requested by the patient
D) Unrelated services performed during an encounter Answer: A Explanation: Medical necessity requires that services are appropriate, necessary, and supported by documentation.
- Which coding guideline addresses sequencing multiple diagnoses? A) The principal diagnosis is listed first, followed by secondary diagnoses B) All diagnoses are listed alphabetically C) The most recent diagnosis is listed first D) Diagnoses are sequenced based on the provider’s preference Answer: A Explanation: Sequencing guidelines specify that the principal diagnosis should be listed first, followed by secondary diagnoses.
- During an audit, a coder finds that a diagnosis code was assigned without sufficient documentation. What is the appropriate action? A) Correct the code to a more general code B) Request clarification from the provider C) Remove the diagnosis code entirely D) Keep the code as is and proceed Answer: B Explanation: The proper action is to seek clarification from the provider to ensure accurate coding.
- Which of the following is a common reason for coding discrepancies identified during external audits? A) Incomplete documentation B) Use of outdated codes
