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Question 1. Which prefix in medical terminology generally indicates "before" or "in front of"? A) Post- B) Pre- C) Sub- D) Hyper- Answer: B Explanation: The prefix "Pre-" means "before" or "in front of," indicating a preceding position or time relative to a reference point. Question 2. In the term "hepatitis," what does the suffix "-itis" signify? A) Inflammation B) Tumor C) Infection D) Disease Answer: A Explanation: The suffix "-itis" indicates inflammation of the organ or tissue, so "hepatitis" refers to inflammation of the liver. Question 3. Which abbreviation is commonly used in inpatient records to denote "nothing by mouth"? A) PO B) NPO C) PRN D) BID Answer: B Explanation: "NPO" stands for "nil per os," meaning nothing by mouth, commonly used before surgeries or procedures. Question 4. The term "cardiomegaly" refers to which of the following? A) Heart inflammation B) Enlarged heart
C) Heart blockage D) Heart failure Answer: B Explanation: "Cardiomegaly" combines "cardio-" (heart) and "-megaly" (enlargement), indicating an enlarged heart. Question 5. Which body system is primarily involved in the process of gas exchange? A) Circulatory system B) Respiratory system C) Nervous system D) Musculoskeletal system Answer: B Explanation: The respiratory system facilitates gas exchange, allowing oxygen in and carbon dioxide out. Question 6. Which of the following is a common pathophysiological feature of congestive heart failure? A) Increased cardiac output B) Decreased venous return C) Impaired cardiac pumping leading to fluid retention D) Elevated blood oxygen levels Answer: C Explanation: Congestive heart failure results from the heart's inability to pump effectively, leading to fluid retention and congestion. Question 7. In ICD- 10 - CM coding, what does the term "use additional code" imply? A) A code that replaces the previous code B) A supplementary code needed for complete documentation C) A code that indicates the primary diagnosis D) An obsolete code Answer: B
A) Diabetes mellitus without complication B) Foot ulcer C) Diabetes mellitus with foot ulcer D) Unspecified foot condition Answer: C Explanation: Coding should reflect both conditions, with the secondary diagnosis specifying the complication—diabetes with foot ulcer. Question 12. What does "POA" indicate in coding documentation? A) Present on Admission B) Postoperative Assessment C) Prior Observation and Action D) Procedure of Admission Answer: A Explanation: "POA" stands for "Present on Admission," indicating whether a condition was present at the time of admission. Question 13. Which of the following is a key component of ICD- 10 - PCS code structure? A) Three characters B) Four characters C) Seven characters D) Ten characters Answer: C Explanation: ICD- 10 - PCS codes consist of seven characters, each providing specific procedural information. Question 14. The root operation "Excision" in ICD- 10 - PCS refers to which type of procedure? A) Cutting out or removing a portion of tissue or an organ B) Repairing or reconnecting tissue C) Destroying tissue
D) Moving tissue from one location to another Answer: A Explanation: "Excision" involves cutting out or removing a portion of tissue or an organ. Question 15. Which approach in ICD- 10 - PCS indicates a procedure performed through a natural or artificial opening using endoscopic guidance? A) Open approach B) Percutaneous approach C) Via Natural or Artificial Opening Endoscopic approach D) External approach Answer: C Explanation: The "Via Natural or Artificial Opening Endoscopic" approach indicates procedure via an endoscope through a natural or artificial opening. Question 16. In ICD- 10 - PCS, what is the purpose of a qualifier? A) To specify the approach used B) To identify the device used C) To provide additional details about the procedure D) To indicate the body part involved Answer: C Explanation: Qualifiers provide additional details about a procedure, such as approach or device specifics. Question 17. Which of the following root operations involves cutting into a body part to explore or examine? A) Inspection B) Resection C) Extirpation D) Reposition Answer: A
Question 21. Which component of the IPPS influences the adjustment of hospital payments based on local wages? A) Disproportionate share adjustment B) Wage index C) Indirect medical education D) Base payment rate Answer: B Explanation: The wage index adjusts payments to account for local variations in hospital labor costs. Question 22. In ICD- 10 - PCS, what does the "root operation" "Replacement" involve? A) Putting in or on biological or synthetic material to replace a body part B) Moving a body part to a different location C) Cutting into a body part D) Removing tissue or an organ without replacement Answer: A Explanation: "Replacement" involves putting in or on biological or synthetic material to replace a body part. Question 23. Which of the following best describes the purpose of the UHDDS? A) To standardize coding practices B) To collect uniform inpatient discharge data for analysis and reporting C) To determine hospital reimbursement rates D) To guide outpatient coding procedures Answer: B Explanation: The UHDDS standardizes data collection for inpatient discharges to facilitate analysis and reporting. Question 24. Under HIPAA, which of the following is considered protected health information (PHI)? A) Patient's social security number B) Patient's favorite color
C) Patient's birthplace D) Patient's occupation Answer: A Explanation: PHI includes demographic data like social security numbers that can identify an individual. Question 25. Which of the following coding practices could constitute fraud? A) Accurate documentation of procedures B) Upcoding to a higher-paying DRG without supporting documentation C) Proper use of POA indicators D) Using official coding guidelines Answer: B Explanation: Upcoding involves assigning a code that reflects a more severe or costly diagnosis or procedure than supported by documentation, constituting fraud. Question 26. What is the primary purpose of coding audits in hospitals? A) To increase the number of codes used B) To ensure compliance and accuracy of coded data C) To reduce documentation requirements D) To assign DRGs manually Answer: B Explanation: Audits verify the accuracy and compliance of coding to ensure proper reimbursement and data quality. Question 27. Which ICD- 10 - CM code range is used for neoplasms? A) C00-D B) E00-E C) F01-F D) G00-G Answer: A
A) Excision B) Removal C) Resection D) Extirpation Answer: D Explanation: "Extirpation" involves taking out or destroying part of a body part, often tissue or foreign material. Question 32. When coding for procedures involving devices, what is essential? A) The device's manufacturer B) The specific device inserted, removed, or replaced C) The patient's response to the device D) The cost of the device Answer: B Explanation: Accurate coding requires identifying the specific device involved in the procedure. Question 33. Which ICD- 10 - PCS approach code indicates a procedure performed via natural or artificial opening with endoscopic assistance? A) 0DJ B) 0EJ C) 0BJ D) 0XJ Answer: B Explanation: The approach code "0EJ" indicates procedure via natural or artificial opening with endoscopic assistance. Question 34. Which of the following is a primary consideration when assigning a DRG? A) The patient's age B) The principal diagnosis and procedures performed C) The hospital's geographic location
D) The length of stay alone Answer: B Explanation: DRG assignment is primarily based on the principal diagnosis, secondary diagnoses, and procedures. Question 35. Under the IPPS, what does the term "relative weight" refer to? A) The importance of the diagnosis B) The comparison of hospital costs for a specific DRG to the national average C) The patient's severity of illness D) The hospital's profit margin Answer: B Explanation: The relative weight reflects the costliness of cases within a DRG relative to the average case. Question 36. Which statement describes the purpose of the "query process" in coding? A) To request clarification from physicians about documentation B) To assign codes without physician input C) To replace documentation deficiencies D) To expedite coding by skipping review Answer: A Explanation: The query process involves requesting clarification from physicians to ensure accurate coding. Question 37. Which of the following is included in the "Chapters" of ICD- 10 - CM? A) Specific disease categories B) Billing procedures C) Hospital administrative codes D) Insurance policies Answer: A Explanation: Chapters in ICD- 10 - CM organize codes by disease categories and body systems.
A) Official Guidelines for Coding and Reporting B) Hospital coding policies C) Billing department procedures D) Medical staff bylaws Answer: A Explanation: The ICD- 10 - CM/PCS Official Guidelines stress documentation's role in accurate coding. Question 42. Which of the following best describes "Reposition" in ICD- 10 - PCS? A) Moving a body part to its normal location B) Removing tissue C) Opening a body part D) Destroying tissue Answer: A Explanation: "Reposition" involves moving a body part to its normal or other desired location. Question 43. Which ICD- 10 - PCS body system code is used for procedures involving the cardiovascular system? A) 0 B) 1 C) 2 D) 3 Answer: A Explanation: The Medical and Surgical section (0) includes procedures across all body systems, including cardiovascular. Question 44. Which of the following is a common external cause code in ICD- 10 - CM? A) W00. B) Z00. C) R50.
D) S01.
Answer: A Explanation: W00.0 indicates a fall involving slipping, tripping, or stumbling. Question 45. Which of the following is true about the "External approach" in ICD- 10 - PCS? A) It involves a procedure performed outside the body B) It involves a surgical incision C) It is used exclusively for imaging procedures D) It indicates minimally invasive surgery Answer: A Explanation: External approach indicates procedures performed outside the body, typically involving external incisions. Question 46. In ICD- 10 - PCS, what does the "Insertion" root operation imply? A) Putting in or on biological or synthetic material B) Removing tissue or an organ C) Cutting into a body part D) Destroying tissue Answer: A Explanation: "Insertion" involves placing a device or material into a body part. Question 47. Which of the following is a key component of the MS-DRG system? A) Coding accuracy B) Patient satisfaction scores C) Hospital accreditation status D) Physician licensing Answer: A Explanation: Accurate coding directly impacts MS-DRG assignment and hospital reimbursement.
C) An external injury D) A congenital anomaly Answer: B Explanation: Sequelae are residual or long-term effects resulting from a previous disease or injury. Question 52. Which code range is used for diseases of the eye and adnexa? A) H00-H B) J00-J C) L00-L D) N00-N Answer: A Explanation: H00-H59 covers diseases of the eye and adnexa. Question 53. The "Fusion" root operation in ICD- 10 - PCS is used to describe procedures that: A) Join two or more vertebrae B) Remove a foreign body C) Reposition a displaced organ D) Destroy abnormal tissue Answer: A Explanation: Fusion joins vertebrae to stabilize the spine. Question 54. Which of the following is an example of a code from ICD- 10 - CM indicating a symptom, sign, or abnormal finding? A) R50. B) C34. C) J45. D) E11. Answer: A Explanation: R50.9 indicates fever, a symptom or abnormal finding.
Question 55. Which ICD- 10 - PCS root operation involves cutting into a body part to separate or split it? A) Division B) Detachment C) Resection D) Extirpation Answer: A Explanation: "Division" involves cutting into a body part to separate or split it. Question 56. Which is true about "Laterality" in ICD- 10 - CM coding? A) It indicates the side of the body affected B) It refers to the patient's age C) It relates to external causes D) It is only used in outpatient coding Answer: A Explanation: Laterality specifies whether a condition affects the left, right, or bilateral sides. Question 57. For which body system would a code like M16.11 be used? A) Musculoskeletal system B) Endocrine system C) Respiratory system D) Nervous system Answer: A Explanation: M16.11 is the ICD- 10 - CM code for unilateral primary osteoarthritis of the hip (musculoskeletal system). Question 58. What does the "Reposition" root operation indicate? A) Moving a body part to its normal or other location B) Removing tissue
Explanation: Reattachment involves reconnecting a previously detached body part. Question 62. Which component of ICD- 10 - PCS code indicates the approach used during a procedure? A) The first character B) The second character C) The sixth character D) The seventh character Answer: C Explanation: In ICD- 10 - PCS, the sixth character indicates the approach (e.g., open, percutaneous). Question 63. In ICD- 10 - CM, which code is used for a myocardial infarction of the anterior wall? A) I21. B) I21. C) I25. D) I50. Answer: A Explanation: I21.09 specifies acute transmural myocardial infarction of the anterior wall. Question 64. Which of the following is an external cause code in ICD- 10 - CM? A) V00.011A B) R50. C) N17. D) C34. Answer: A Explanation: V00.011A indicates a fall from stairs, external cause. Question 65. The term "Sequela" in ICD- 10 - CM is used to code: A) Past injuries or diseases resulting in residual effects B) Current active diseases
C) External causes of injury D) Symptoms of unknown origin Answer: A Explanation: Sequela codes indicate residual effects of previous diseases or injuries. Question 66. Which of the following ICD- 10 - PCS root operations involves putting in or on biological or synthetic material? A) Insertion B) Replacement C) Reposition D) Revision Answer: A Explanation: "Insertion" involves placing a device or material into the body. Question 67. Which section of ICD- 10 - PCS would include coding for radiology procedures? A) Imaging (B) B) Medical and Surgical (0) C) Measurement and Monitoring (4) D) Ancillary (C, D, etc.) Answer: A Explanation: The Imaging section (B) covers radiology procedures. Question 68. The ICD- 10 - CM code for a benign skin neoplasm is: A) D22. B) L81. C) N48. D) M79. Answer: A Explanation: D22.9 is for benign neoplasm of skin, unspecified.
