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Test Bank For
Elsevier Inc ICD-10-CMPCS Coding Theory and Practice, 2025 2026 Copyright 2025
Chapter 1-
Chapter 01: The Rationale for and History of Coding
MULTIPLE CHOICE
1. Which of the following would NOT be studied through the use of ICD-10-CM?
a. Patterns of disease
b. Causes of pregnancy
c. Disease epidemics
d. Causes of mortality
ANS: B DIF: M REF: p. 2 OBJ: 1 TOP: Background
2. In a closed system such as the ICD-10-CM system, a disease or condition can be classified
only in ____ location(s).
a. one
b. two
c. three
d. four
ANS: A DIF: M REF: p. 2 OBJ: 2 TOP: Classification
3. Which organization is NOT responsible for the maintenance of ICD-10-CM?
a. National Center for Health Statistics (NCHS)
b. American Academy of Professional Coders (AAPC)
c. American Hospital Association (AHA)
d. American Health Information Management Association (AHIMA)
ANS: B DIF: M REF: p. 3 OBJ: 3 TOP: History
4. As explained in the article that appeared in AHIMA by Joette Hanna titled “Constructing a
Coding Compliance Plan,” several steps must be taken for a coding department to be certain
the department is in compliance. Which of the following is NOT one of the steps?
a. Abide by AHIMA’s Standards of Ethical Coding.
b. Develop coding policies and procedures.
c. Conduct coding audits.
d. Follow the Coding Clinic Guidelines.
ANS: D DIF: D REF: p. 6 OBJ: 6 TOP: Compliance
5. A nomenclature is a system of ____ as used in preferred terminology.
a. diseases
b. procedures
c. conditions
d. names
ANS: D DIF: M REF: p. 2 OBJ: 2 TOP: Nomenclature
6. Nomenclature of diseases was first developed in the United States around ____.
a. 1893
b. 1958
c. 1928
d. 1898
ANS: C DIF: M REF: p. 2 OBJ: 2 TOP: History
7. The ICD-10-CM classification system is a closed system composed of ____.
a. diseases
b. symptoms
c. injuries
d. all of the above
ANS: D DIF: M REF: p. 2 OBJ: 2 TOP: History
8. The ____ Bills of Mortality in the 17th century was the first attempt to statistically gather data
on disease.
a. Paris
b. London
c. France
d. England
ANS: B DIF: M REF: p. 2 OBJ: 2 TOP: History
9. Clinical Modification (CM) was developed in ____ by the United States to more accurately
capture morbidity data for study within the United States and operative and diagnostic
procedures that were not included in the original publication of ICD.
a. 1877
b. 1947
c. 1977
d. 1997
ANS: C DIF: M REF: p. 3 OBJ: 2 TOP: History
10. In ICD-10-CM the CM stands for ____.
a. Clinical Modification
b. Centers for Medicaid and Medicare
c. Core Measures
d. Chief Medical Officer
ANS: A DIF: E REF: p. 3 OBJ: 1
ANS: C DIF: M REF: p. 6 OBJ: 6 TOP: Compliance
17. Personal health information can be shared with ____.
a. those who have a need to know
b. people requesting information on the phone
c. your neighbors
d. all of the above
ANS: A DIF: E REF: p. 7 OBJ: 7 TOP: Confidentiality
18. Which coding credential requires coders to be familiar with Hierarchical Condition Categories
(HCCs), which are the basis for reimbursement for Medical Advantage plans?
a. CIC
b. CRC
c. CPC
d. CCS-P
ANS: B DIF: M REF: p. 4 OBJ: 4 TOP: Credentials TRUE/FALSE
1. Procedures for processing claim rejections should be included in a coding compliance plan.
ANS: T DIF: E REF: p. 7 OBJ: 6 TOP: Compliance
2. It is acceptable to share personal information about a patient’s medical history with anyone
who requests this information.
ANS: F DIF: E REF: p. 7 OBJ: 7 TOP: Confidentiality
3. Coded data are used for only one purpose.
ANS: F DIF: E REF: p. 2 OBJ: 1 TOP: Application
4. CCS-P stands for Certified Coding Specialist–Pediatric Based.
ANS: F DIF: E REF: p. 4 OBJ: 4 TOP: Credentials
5. CPB stands for Certified Physician Biller
ANS: F DIF: E REF: p. 4 OBJ: 4 TOP: Credentials
6. Both AHIMA and AAPC have standards for ethical coding.
ANS: T DIF: E REF: p. 4 OBJ: 5 TOP: Coding Ethics
7. Compliance officers and programs are found only in healthcare organizations.
ANS: F DIF: E REF: p. 6 OBJ: 6 TOP: Compliance
8. Compliance is defined as acting according to certain accepted standards or, in simple terms,
abiding by the rules.
ANS: T DIF: E REF: p. 6 OBJ: 6 TOP: Compliance COMPLETION
1. Without the __________ system, the comparison of data would be impossible.
ANS: classification
DIF: M REF: p. 2 OBJ: 2 TOP: History
2. ICD-10-CM/PCS can be updated _________ times each year.
ANS:
two
DIF: E REF: p. 3 OBJ: 2 TOP: History
3. To maintain their credentials, coders must earn __________.
ANS:
continuing education units (CEUs)
continuing education units
CEUs
DIF: E REF: p. 4 OBJ: 4 TOP: Coding Organizations
4. WHO stands for __________.
ANS: World Health Organization
DIF: E REF: p. 3 OBJ: 2 TOP: Abbreviations
5. HIPAA stands for __________ of 1996.
ANS: Health Insurance Portability and Accountability Act
DIF: E REF: p. 6 OBJ: 8 TOP: Abbreviations
Chapter 02: The Health Record as the Foundation of Coding
ICD-10-CM/PCS Coding: Theory and Practice, 2025/2026 Edition
MULTIPLE CHOICE
1. Which is the area of the record where the attending physicians, as well as physician
consultants, give their directives to the house staff, nursing, and ancillary services?
a. Nursing notes
b. Anesthesia forms
c. Physician orders
d. Progress notes
ANS: C DIF: D REF: p. 16 OBJ: 1 TOP: Sections of the Health Record
2. What does EKG stand for?
a. Electrocardiogram
b. Electroencephalogram
c. Electrokariesogram
d. Electromagnetic
ANS: A DIF: E REF: p. 36 OBJ: 1 TOP: Abbreviations
3. Sometimes ____ is/are used to help diagnose a patient’s condition.
a. x-rays
b. history and physical
c. documentation
d. a discharge disposition
ANS: A DIF: M REF: p. 36 OBJ: 6 TOP: Guidelines for Diagnosis
4. Which of these is NOT considered a physician?
a. Internist
b. Hospitalist
c. Resident
d. Medical student
ANS: D DIF: E REF: p. 39 OBJ: 6 TOP: Coding from Documentation Found in the Health Record
5. If the condition of a patient is being clinically evaluated, the coder would expect to see ____.
a. an admission date
b. letters
c. clinical observations
d. an operative report
ANS: C DIF: D REF: p. 36 OBJ: 4 TOP: Guidelines for Diagnosis
6. In some cases, a patient is ready to be discharged from the hospital, but at the last minute, the
patient develops a condition that requires him or her to stay an additional night. An example
of when a patient might have to stay an additional night is when the patient ____.
a. is feeling better
b. has no pain
c. has no additional cough
d. develops a fever
ANS: D DIF: E REF: p. 36 OBJ: 4 TOP: Guidelines for Diagnosis
7. The AHIMA practice brief says that a physician query should____.
a. “lead” the physician
b. contain precise language
c. be written on scratch paper
d. sound presumptive
ANS: B DIF: M REF: p. 41 OBJ: 7 TOP: Coding from Documentation Found in the Health Record
8. Chronic conditions include all of the following EXCEPT ____.
a. hypertension
b. congestive heart failure
c. diverticulitis
d. emphysema
e. all of the above are correct
ANS: C DIF: M REF: p. 37 OBJ: 4 TOP: Reasons for Assigning Other Diagnoses
9. A query should contain all of the following items EXCEPT ____.
a. date of service
b. amount of increased reimbursement due to query
c. patient name
d. area for provider signature
ANS: B DIF: M REF: p. 42 OBJ: 7 TOP: Explain the Physician Query Process TRUE/FALSE
1. It is the responsibility of a coder to extract from the health record the diagnoses and
procedures for which a patient is being treated.
ANS: T DIF: M REF: p. 34 OBJ: 5 TOP: Standards for Diagnosis and Procedures
2. Abnormal findings (lab, x-ray, pathologic, and other diagnostic results) are always coded and
reported when they are found.
ANS: F DIF: M REF: p. 38 OBJ: 5 TOP: Guidelines for Diagnosis
ANS: C DIF: M REF: p. 66 OBJ: 2 TOP: Coding Conventions
2. ____ is/are used in both the Index and Tabular List to enclose supplementary words that may
be present or absent in the statement of a disease or procedure without affecting the code
assignment.
a. Excludes
b. Brackets
c. Includes
d. Parentheses
ANS: D DIF: E REF: p. 57 OBJ: 2 TOP: Coding Conventions
3. Which statement is NOT true of inclusion terms?
a. An “inclusion note” under a code indicates that the terms excluded from the code
are to be coded elsewhere.
b. The terms may be included under some codes.
c. These terms are the conditions for which that code number is to be used.
d. The inclusion terms are not necessarily exhaustive.
ANS: A DIF: M REF: p. 61 OBJ: 2 TOP: Coding Conventions
4. The word(s) “____” should be interpreted to mean either “and” or “or” when it appears in the
title.
a. with
b. see
c. omit code
d. and
ANS: D DIF: E REF: p. 66 OBJ: 2 TOP: Coding Conventions
5. “____” is used in the Alphabetic Index to provide guidance when two conditions are related or
have a causal relationship.
a. With
b. See condition
c. See category
d. And
ANS: A DIF: M REF: p. 66 OBJ: 2 TOP: Coding Conventions
6. What does CPT stand for?
a. Coding Principals Together
b. Current Practice Theory
c. Chapter Procedure Theory
d. Current Procedural Terminology
ANS: D DIF: M REF: p. 45 OBJ: 1 TOP: Abbreviations
7. “Diseases of the skin and subcutaneous tissue (L00-L99)” represents a ____.
a. chapter
b. section
c. category
d. subcategory
ANS: A DIF: E REF: p. 51 OBJ: 1 TOP: Format of ICD-10-CM Code Book
8. “Infections of skin and subcutaneous tissue (L00-L08)” represents a ____.
a. chapter
b. section
c. category
d. subcategory
ANS: B DIF: E REF: p. 51 OBJ: 1 TOP: Format of ICD-10-CM Code Book
9. The code “L01 impetigo” represents a ____.
a. chapter
b. section
c. category
d. subcategory
ANS: C DIF: E REF: p. 51 OBJ: 1 TOP: Format of ICD-10-CM Code Book
10. The code “L05.0 pilonidal cyst and sinus with abscess” represents a ____.
a. chapter
b. section
c. category
d. subcategory
ANS: D DIF: E REF: p. 52 OBJ: 1 TOP: Format of ICD-10-CM Code Book
11. The bolded subterm in the diagnostic statement cortical cataract is a(n) ____ modifier.
a. essential
b. nonessential
ANS: B DIF: E REF: p. 57 OBJ: 2 TOP: Modifiers
12. The bolded subterm in the diagnostic statement aspiration pneumonia is a(n) ____ modifier.
a. essential
b. nonessential
ANS: A DIF: E REF: p. 55 OBJ: 2 TOP: Modifiers
13. The bolded subterm in the diagnostic statement purulent pneumonia is a(n) ____ modifier.
a. essential
ANS: T DIF: M REF: p. 52 OBJ: 1 TOP: Format COMPLETION
1. “__________” is used in the Alphabetic Index to provide guidance when two conditions are
related or have a causal relationship.
ANS: Due to or with
DIF: M REF: p. 55 | p. 66 OBJ: 2 TOP: Coding Conventions
2. The word “__________” in the Alphabetic Index is sequenced immediately following the
main term, not in alphabetic order.
ANS: with
DIF: M REF: p. 66 OBJ: 2 TOP: Coding Conventions
3. __________, a form of punctuation, are used in the index to identify manifestation codes in
the Alphabetic Index.
ANS: Brackets
DIF: M REF: p. 57 OBJ: 2 TOP: Coding Conventions
4. A(n) __________ is a term that is enclosed in parentheses following a main term or a subterm
and whose presence or absence has no effect on code assignment.
ANS: nonessential modifier
DIF: M REF: p. 57 OBJ: 2 TOP: Coding Conventions
Chapter 04: Basic Steps of Coding
ICD-10-CM/PCS Coding: Theory and Practice, 2025/2026 Edition
MULTIPLE CHOICE
1. 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
ANS: C DIF: M REF: p. 70 OBJ: 3 TOP: Review of the Health Record
2. The main term in “aplastic anemia” is ____.
a. anemia
b. aplasia
c. aplastic
d. none of the above
ANS: A DIF: M REF: p. 71 OBJ: 1 TOP: Alphabetic Index
3. 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.
ANS: D DIF: M REF: p. 71 OBJ: 3 TOP: Review of the Health Record
4. When evaluating an ER record, a coder should look for the ____.
a. diagnosis
b. chief complaint
c. probable diagnosis
d. differential diagnosis
ANS: B DIF: M REF: p. 71 OBJ: 3 TOP: Review of the Health Record
5. 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 List.
d. All of the options are correct.
ANS: D DIF: M REF: p. 70 OBJ: 3 TOP: Basic Steps of Coding
6. 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
ANS: C DIF: M REF: p. 72 OBJ: 1 TOP: Alphabetic Index TRUE/FALSE
1. The coder should rely solely on the discharge summary to capture all of the diagnoses and
procedures that were treated and performed.
ANS: F DIF: E REF: pp. 70-71 OBJ: 3
DIF: M REF: p. 70 OBJ: 3 TOP: Review of the Health Record
Chapter 05: General Coding Guidelines for Diagnosis
ICD-10-CM/PCS Coding: Theory and Practice, 2025/2026 Edition
MULTIPLE CHOICE
1. Etiology/manifestation convention requires ____ code(s) to fully describe a single condition
that affects multiple body systems.
a. one
b. two
c. three
d. zero
ANS: B DIF: M REF: p. 81 OBJ: 1 TOP: General Coding Guidelines
2. A(n) ____ is a residual effect (condition produced) after the acute phase of an illness or injury
has terminated.
a. combination effect
b. acute effect
c. sequela
d. chronic effect
ANS: C DIF: E REF: p. 84 OBJ: 1 TOP: ICD-10-CM Official Guidelines for Coding and Reporting TRUE/FALSE
1. The selection of codes A00.0 through T88.9, Z00-Z99.89 is NOT used frequently to describe
the reason for the admission/encounter.
ANS: F DIF: E REF: p. 80 OBJ: 1 TOP: General Coding Guidelines
2. Principal diagnosis is defined in the Uniform Hospital Discharge Data Set (UHDDS) as that
condition established after study to be chiefly responsible for occasioning the admission of the
patient to the hospital for care.
ANS: T DIF: E REF: p. 87 OBJ: 2 TOP: Selection of Principal Diagnosis
3. Codes for symptoms, signs, and ill-defined conditions are NOT to be used as a principal
diagnosis when a related definitive diagnosis has been established.
ANS: T DIF: E REF: p. 87 OBJ: 2 TOP: Selection of Principal Diagnosis
4. If a diagnosis is documented as possible at the time of discharge from an inpatient stay, code
the condition as if it exists.
ANS: T DIF: M REF: p. 89 OBJ: 2 TOP: Selection of Principal Diagnosis
5. Conditions that are routinely associated with a disease or condition should not be coded as
additional diagnoses unless instructed by the classification or unless they affect the patient’s
condition or treatment given.
ANS: T DIF: E REF: p. 90 OBJ: 1 TOP: Coding Guidelines
6. In the inpatient setting, it is not acceptable to code diagnoses that have not yet been confirmed
and are questionable or suspected at the time of discharge.
ANS: F DIF: E REF: p. 89 OBJ: 1 TOP: Coding Guidelines
7. When you assign separate codes that are used to identify acute and chronic conditions, the
acute code is sequenced first.
ANS: T DIF: E REF: p. 82 OBJ: 1 TOP: Coding Guidelines
8. If a patient is admitted for a complication due to a surgical procedure, the reason for the
surgical procedure is the principal diagnosis.
ANS: F DIF: E REF: p. 88 OBJ: 2 TOP: Selection of Principal Diagnosis
9. When the patient is admitted for a complication due to a surgical procedure, the complication
is the principal diagnosis.
ANS: T DIF: M REF: p. 88 OBJ: 2 TOP: Selection of Principal Diagnosis
10. If the principal diagnosis was abdominal pain due to acute appendicitis, the abdominal pain
would be coded as a secondary diagnosis.
ANS: F DIF: M REF: p. 80 OBJ: 2 | 3 TOP: Selection of Principal Diagnosis
11. When a coder notices on a laboratory test result that a patient’s sodium is below normal, it is
acceptable to code hyponatremia.
ANS: F DIF: E REF: p. 91 OBJ: 1 TOP: Abnormal Laboratory Results COMPLETION
1. A(n) __________ code is a single code used to classify two diagnoses, a diagnosis with an
associated secondary process, or a diagnosis with an associated complication.
TOP: Format
6. ICD-10-PCS is divided into how many sections?
a. 7
b. 10
c. 14
d. 17
ANS: D DIF: M REF: p. 95 OBJ: 1 TOP: Format
7. Which of the following is a characteristic of ICD-10-PCS?
a. Codes are numeric.
b. It is similar to ICD-10-CM diagnoses codes.
c. The letters “I” and “O” are not used.
d. Codes are three to four digits.
ANS: C DIF: E REF: p. 94 OBJ: 1 TOP: Format
8. Which of the following is a characteristic of ICD-10-PCS?
a. Codes have a decimal point.
b. It is similar to ICD-10-CM codes.
c. There are a limited number of codes.
d. Codes are seven characters.
ANS: D DIF: E REF: p. 94 OBJ: 1 TOP: Format
9. The fourth character of an ICD-10-PCS code represents a(an) ____.
a. body part
b. approach
c. section
d. device
ANS: A DIF: M REF: p. 101 OBJ: 1 TOP: Format
10. The sixth character of an ICD-10-PCS code represents a ____.
a. device
b. root operation
c. qualifier
d. body system
ANS: A DIF: M REF: p. 105 OBJ: 1 TOP: Format
11. Cutting off all or a portion of the upper or lower extremities is ____.
a. destruction
b. fragmentation
c. detachment
d. resection
ANS: C DIF: M REF: p. 98 OBJ: 2 TOP: Root Operation
12. Taking or letting out fluids and/or gases from a body part is called ____.
a. extirpation
b. fragmentation
c. extraction
d. drainage
ANS: D DIF: M REF: p. 98 OBJ: 2 TOP: Root Operation
13. Cutting out or off, without replacement, a portion of a body part is called ____.
a. resection
b. excision
c. destruction
d. extraction
ANS: B DIF: M REF: p. 98 OBJ: 2 TOP: Root Operation
14. Freeing a body part from an abnormal physical constraint is called ____.
a. reposition
b. division
c. release
d. transfer
ANS: C DIF: M REF: p. 98 OBJ: 2 TOP: Root Operation
15. Moving all or a portion of a body part to its normal location or other suitable location is called
____.
a. reposition
b. release
c. transfer
d. transplantation
ANS: A DIF: M REF: p. 99 OBJ: 2 TOP: Root Operation
16. Cutting into a body part without draining fluids and/or gases from the body part in order to
separate or transect a body part is called ____.
a. reattachment
b. release
c. transfer
d. division
ANS: D DIF: M REF: p. 98 OBJ: 2 TOP: Root Operation
17. Completely closing an orifice or lumen of a tubular body part is called ____.
a. bypass
b. restriction
