ICD-10-CM Coding: Master the Basics for Accurate Medical Documentation

Question 1

Which statement deviates from the fundamental principles of ICD-10-CM coding?

Accepted Answer

Assign multiple codes for a single diagnosis.

Answer

Assign codes with maximum specificity.

Answer

Prioritize coding the primary reason for the patient's visit.

Answer

Use the present on admission (POA) indicator accurately.

Question 2

Which ICD-10-CM modifier is NOT used to indicate the side of the body where a procedure was performed?

Accepted Answer

US

Answer

LT

Answer

RT

Question 3

What is a key advantage of using ICD-10-CM coding compared to ICD-9-CM coding?

Accepted Answer

Enhanced accuracy and detail in coding

Answer

Lower administrative expenses

Answer

No need for extra documentation

Answer

Simplified coding procedures

Question 4

Which fundamental principle guides the assignment of ICD-10-CM codes?

Accepted Answer

Selecting the code with the highest level of specificity for the patient's condition

Answer

Coding based on documented signs and symptoms, even if the underlying condition is not stated

Answer

Coding only the primary diagnosis and excluding secondary or tertiary diagnoses

Answer

Using codes exclusively from a specific chapter or section of the ICD-10-CM manual

Question 5

In ICD-10-CM coding, which root operation is used to code for the removal of a skin lesion?

Accepted Answer

Excision

Answer

Incision

Answer

Drainage

Answer

Repair

Question 6

In ICD-10-CM coding, what's the main rule for assigning codes?

Accepted Answer

Code all diagnoses and procedures in the patient's record.

Answer

Code only the main diagnosis and procedure.

Answer

Code only the most serious diagnosis and procedure.

Answer

Code based on the patient's symptoms.

Question 7

In ICD-10-CM coding, which code indicates an acute myocardial infarction without a specific location?

Accepted Answer

I21.9

Answer

I22.0

Answer

I23.1

Answer

I24.1

Question 8

Which core principle underpins ICD-10-CM coding?

Accepted Answer

Codes are structured hierarchically, enabling precise coding.

Answer

Coding relies solely on the patient's reported symptoms.

Answer

Codes must be assigned in chronological order, reflecting the sequence of events.

Answer

Coding focuses solely on primary diagnoses, excluding secondary conditions.

Question 9

Which type of code is NOT part of the ICD-10-CM classification system?

Accepted Answer

Revenue codes

Answer

Diagnosis codes

Answer

Procedure codes

Answer

External cause codes

Question 10

Which of the following is NOT a fundamental root operation in ICD-10-CM coding?

Accepted Answer

Evaluation

Answer

Incision

Answer

Excision

Answer

Ligation

Question 11

In ICD-10-CM coding, which code type is used to identify the external cause of an injury due to a fall?

Accepted Answer

External cause code

Answer

Disease code

Answer

Procedure code

Question 12

What is the primary function of the ICD-10-CM coding system?

Accepted Answer

Establish a clear framework for categorizing and recording medical diagnoses and procedures.

Answer

Function as a comprehensive billing system for healthcare services.

Answer

Provide a basis for conducting research in healthcare.

Answer

Track patient outcomes and assess treatment effectiveness.

Question 13

In ICD-10-CM, which code range is used for an accidental fall from a height?

Accepted Answer

W00-W19: Falls

Answer

V00-V99: External causes of injury and poisoning

Answer

S00-T98: Injuries to the skin and subcutaneous tissue

Answer

M00-M99: Musculoskeletal and connective tissue diseases

Question 14

According to ICD-10-CM guidelines, when multiple diagnoses or procedures are present in a patient's medical record, which principle should be applied to determine the principal code assignment?

Accepted Answer

Select the code for the condition that most closely aligns with the patient's primary reason for visit.

Answer

Select the code for the condition with the highest potential for reimbursement.

Answer

Select the code for the condition that is easiest to code.

Answer

Select the code for the condition with the most severe prognosis.

Question 15

In ICD-10-CM coding, which modifier is used to indicate a medical procedure performed on the left side of the body?

Accepted Answer

LT

Answer

RT

Answer

BIL

Answer

NOS

Question 16

What is the primary purpose of the International Classification of Diseases, 10th Revision, Clinical Modification (ICD-10-CM) coding system in healthcare?

Accepted Answer

To create a standardized language for documenting medical diagnoses and procedures, ensuring clear communication among healthcare professionals.

Answer

To determine a patient's eligibility for health insurance coverage based on their medical history.

Answer

To track the prevalence of specific diseases within a population for epidemiological research.

Answer

To establish specific treatment plans for various medical conditions based on their severity.

Question 17

In ICD-10-CM training, what is the main purpose of case studies and practice coding exercises?

Accepted Answer

To create real-world medical situations that help students apply ICD-10-CM coding principles in a practical way.

Answer

To test students' knowledge of ICD-10-CM coding rules only.

Answer

To give students many exercises to memorize ICD-10-CM codes without focusing on how to use them in practice.

Question 18

In ICD-10-CM coding, which factor is essential for selecting the most appropriate code?

Accepted Answer

Laterality of the condition

Answer

Patient's age

Question 19

In ICD-10-CM coding, when assigning a code for a procedure involving body part removal, which root operation code should be used?

Accepted Answer

Excision

Answer

Incision

Answer

Repair

Answer

Destruction

Question 20

Which principle in ICD-10-CM coding stresses the need for thorough and detailed information?

Accepted Answer

Specificity and detail

Answer

Symptom-based coding

Answer

Physician-exclusive coding

Question 21

How does the enhanced specificity and increased granularity of ICD-10-CM coding affect medical coders?

Accepted Answer

Poses challenges in code selection but improves coding accuracy.

Answer

Simplifies coding tasks due to a more straightforward classification structure.

Answer

Has no significant impact on coding efficiency or precision.

Question 22

Which of the following is **NOT** a principle of ICD-10-CM coding?

Accepted Answer

Assign codes based on the patient's symptoms.

Answer

Code to the highest level of specificity.

Answer

Use only the code that best describes the patient's condition.

Question 23

Which ICD-10-CM modifier indicates a procedure performed on the left side of the body?

Accepted Answer

LT

Answer

RT

Answer

LLQ

Question 24

When coding for a condition affecting the left knee using ICD-10-CM, which laterality indicator should be used?

Accepted Answer

Left

Answer

Right

Answer

Not applicable

Question 25

To ensure the most accurate and up-to-date coding information, which resource should you consult to find a newly introduced ICD-10-CM code for a specific medical condition?

Accepted Answer

Official ICD-10-CM website

Answer

Medical encyclopedia

Answer

Coding textbook

Answer

Online discussion group for coders

Question 26

When coding a surgical procedure, the correct root operation should be selected based on which of the following factors?

Accepted Answer

Primary intent of the surgery

Answer

Anatomic location of the procedure

Answer

Type of surgical approach

Answer

Patient's medical history

Question 27

Which of the following is NOT a type of chapter in the ICD-10-CM coding system?

Accepted Answer

Legal codes

Answer

Infectious and parasitic diseases

Answer

Diseases of the digestive system

Answer

Mental health disorders

Question 28

What is the significance of the seventh character in an ICD-10-CM code?

Accepted Answer

It indicates the laterality (left/right) of the condition or procedure.

Answer

It specifies the episode of care (initial, subsequent, etc.).

Answer

It denotes the severity of the condition.

Answer

It is used exclusively for coding unspecified conditions.

Question 29

How should unspecified codes be used in ICD-10-CM?

Accepted Answer

Only when there is absolutely no other code that accurately describes the condition.

Answer

As the first choice for coding any condition.

Answer

When the provider is unsure of the specific diagnosis.

Answer

When the patient's condition is not clearly documented.

Question 30

What is the fundamental difference between a primary diagnosis and a secondary diagnosis?

Accepted Answer

The primary diagnosis is the main reason for the patient's visit, while the secondary diagnosis is a co-existing condition.

Answer

The secondary diagnosis is the main reason for the patient's visit, while the primary diagnosis is a co-existing condition.

Answer

Primary and secondary diagnoses are interchangeable terms.

Answer

There is no difference between a primary and a secondary diagnosis.

Question 31

What is the primary purpose of using a code book in ICD-10-CM coding?

Accepted Answer

To locate the appropriate code for a given diagnosis or procedure.

Answer

To learn the definitions of medical terms.

Answer

To understand the guidelines for coding.

Answer

To keep track of coded information.

Question 32

When assigning ICD-10-CM codes, a bilateral laterality indicator (RT/LT) should be used for conditions affecting which of the following?

Accepted Answer

Paired organs or body parts, like cataracts in both eyes

Answer

A single body part, like a broken left leg

Answer

A single organ, like pneumonia in the right lung

Answer

Conditions with unspecified laterality, like a rash without indication of the affected side

Question 33

When coding an external cause of injury or illness using ICD-10-CM, which guideline should be followed?

Accepted Answer

Code the external cause using the appropriate code from Chapter 19: Injury, Poisoning and Certain Other Consequences of External Causes.

Answer

Code only the underlying cause, not the external cause.

Answer

Code the external cause only if it is the primary cause of the injury or illness.

Question 34

What is the primary purpose of using external cause codes in ICD-10-CM coding?

Accepted Answer

To capture factors that may have contributed to an injury or illness

Answer

To identify the underlying cause of an injury or illness

Answer

To provide a code for a specific type of trauma

Answer

To indicate the patient's occupation

Question 35

In ICD-10-CM, which modifier signifies a procedure was performed on the right side of the body?

Accepted Answer

RT

Answer

LT

Answer

BIL

Answer

QU

Question 36

When coding for the presence or absence of a symptom or sign using ICD-10-CM, which guideline should be followed?

Accepted Answer

Code for the absence of a symptom or sign only if it is specifically documented as being absent.

Answer

Code for the specific symptom or sign, regardless of whether it is present or absent.

Answer

Always code for the most severe symptom or sign present.

Question 37

When is it appropriate to use an 'E' code?

Accepted Answer

To indicate an external cause of injury, poisoning, or other adverse effect

Answer

To specify a comorbidity

Answer

To report a complication

Answer

To describe a social history

Question 38

What is the primary purpose of distinguishing between a primary and secondary diagnosis code?

Accepted Answer

To indicate the main reason for the encounter and any contributing conditions

Answer

To assign equal importance to all diagnoses

Answer

To specify the chronological order of diagnoses

Answer

To differentiate between acute and chronic conditions

Question 39

What is the purpose of using a combination code?

Accepted Answer

To describe a condition that cannot be adequately coded with a single code

Answer

To indicate that multiple conditions are present

Answer

To specify the laterality of a condition

Answer

To provide additional information about a condition

Question 40

When assigning codes using ICD-10-CM, which principle ensures the most accurate representation of a patient's condition?

Accepted Answer

Choose the most specific code that precisely describes the patient's condition.

Answer

Code based solely on symptoms, regardless of the underlying cause.

Answer

Select the most general code that covers all possible diagnoses.

Answer

Code solely based on the physician's notes, even if incomplete or unclear.

Question 41

Which of the following ICD-10-CM codes represents a laceration on the left leg?

Accepted Answer

S49.221A: Laceration of lower leg, left, initial encounter

Answer

S49.221B: Laceration of lower leg, left, subsequent encounter

Answer

S49.221C: Laceration of lower leg, left, unspecified encounter

Answer

S49.221D: Laceration of lower leg, left, encounter for sequela

Question 42

What is the primary function of ICD-10-CM coding?

Accepted Answer

To assign standardized codes to diagnoses, symptoms, and procedures for efficient medical documentation

Answer

To track patient demographics and personal information

Answer

To exclusively bill for medical services and treatments

Answer

To create and maintain electronic health records

Question 43

Which code type is NOT part of the ICD-10-CM coding system?

Accepted Answer

Social history code

Answer

Diagnosis code

Answer

Procedure code

Answer

External cause of injury code

Question 44

Select the valid ICD-10-CM code for essential hypertension:

Accepted Answer

I10.0

Answer

I11.0

Answer

I12.0

Answer

I13.0

Question 45

Identify the appropriate ICD-10-CM code for a laparoscopic appendectomy:

Accepted Answer

44.04

Answer

44.02

Answer

44.06

Answer

44.08

Question 46

Explain the difference between an alphabetic index and a tabular index in ICD-10-CM.

Accepted Answer

An alphabetic index arranges codes alphabetically, while a tabular index arranges codes numerically.

Answer

An alphabetic index is used for diagnosis codes, and a tabular index is used for procedure codes.

Answer

There is no difference between an alphabetic index and a tabular index in ICD-10-CM.

Answer

A tabular index is more comprehensive and detailed than an alphabetic index.

Question 47

Which resource provides official guidance on the use of ICD-10-CM codes?

Accepted Answer

ICD-10-CM Official Guidelines for Coding and Reporting

Answer

AMA Coding Today

Answer

CMS MLN Matters

Answer

National Correct Coding Initiative

Question 48

What is the primary purpose of using ICD-10-CM codes?

Accepted Answer

To provide clear and standardized reporting of diagnoses and procedures

Answer

To assign codes for reimbursement of medical services

Answer

To track the prevalence and mortality rates of specific diseases

Answer

To offer clinical guidance for healthcare providers

Question 49

What specific information is conveyed by the seventh character in an ICD-10-CM code?

Accepted Answer

Laterality

Answer

Severity

Answer

Etiology

Answer

Manifestation

Question 50

Which of the following is a valid ICD-10-CM code for essential hypertension?

Accepted Answer

I10

Answer

J10

Answer

K10

Answer

L10

Question 51

What is the key difference between an ICD-10-CM diagnosis code and a procedure code?

Accepted Answer

Diagnosis codes describe conditions, while procedure codes describe actions taken

Answer

Procedure codes are more specific than diagnosis codes

Answer

Diagnosis codes are only used for inpatient services, while procedure codes are used for both inpatient and outpatient services

Answer

Procedure codes are assigned by physicians, while diagnosis codes are assigned by coders

Question 52

What is the appropriate ICD-10-CM code for a patient with a history of myocardial infarction who has undergone subsequent coronary artery bypass grafting?

Accepted Answer

I25.11

Answer

I21.4

Answer

I24.9

Answer

I22.0

Question 53

A patient undergoes a surgical procedure to remove a cancerous tumor from their colon. Which root operation best describes the nature of this surgical intervention?

Accepted Answer

Excision

Answer

Incision

Answer

Drainage

Answer

Repair

Question 54

Why are laterality indicators crucial in ICD-10-CM coding? Provide examples of their practical use.

Accepted Answer

Laterality indicators pinpoint the affected body side in medical conditions and procedures.

Answer

Laterality indicators are only used in surgical coding, not in medical diagnoses.

Answer

ICD-10-CM coding guidelines do not include laterality indicators.

Question 55

In ICD-10-CM coding, which placeholder represents incomplete or uncertain information in a diagnosis or procedure?

Accepted Answer

X

Answer

0

Answer

*

Answer

#

Question 56

When coding complex medical cases, which principle should be followed to prioritize interrelated diagnoses and determine the correct sequence of ICD-10-CM codes?

Accepted Answer

Code First

Answer

Rule of Three's

Answer

Alphabetical Order

Answer

Chronological Order

Question 57

A patient has both chronic obstructive pulmonary disease (COPD) and pneumonia.  Which ICD-10-CM code should be reported as the primary diagnosis?

Accepted Answer

J15.0 Pneumonia

Answer

J44.0 Chronic obstructive pulmonary disease

Answer

J44.0 with J15.0

Question 58

As a medical coder, which ethical obligation is paramount?

Accepted Answer

Adhering to coding guidelines and regulations

Answer

Prioritizing financial gain over patient well-being

Answer

Sharing patient information without consent

Answer

Modifying medical records for personal benefit

Question 59

For a closed fracture of the distal radius, select the correct ICD-10-CM code.

Accepted Answer

S52.521A

Answer

S52.021A: Open fracture of the distal end of the radius

Answer

S52.421A: Closed fracture of the shaft of the radius

Answer

S52.221A: Closed fracture of the proximal end of the radius

Question 60

Select the correct ICD-10-CM code for a myocardial infarction with ST-segment elevation.

Accepted Answer

I21.4

Answer

I21.1: Anterior wall myocardial infarction

Answer

I21.3: Myocardial infarction of the right ventricle

Answer

I21.0: Acute myocardial infarction of unspecified site

Question 61

For a sprain of the left ankle, select the appropriate ICD-10-CM code.

Accepted Answer

S93.421A

Answer

S93.021A: Sprain of the right ankle

Answer

S93.221A: Sprain of the knee

Answer

S93.621A: Sprain of the wrist

Question 62

What is the purpose of the seventh character in an ICD-10-CM code for a body structure?

Accepted Answer

To indicate the laterality of a condition or procedure.

Answer

To provide additional specificity.

Answer

To differentiate between different types of the same condition.

Question 63

Which of the following would be considered a chronic condition according to ICD-10-CM?

Accepted Answer

Diabetes mellitus type 2

Answer

Sprain of the ankle

Answer

Appendicitis

Answer

Influenza

Question 64

When coding a diagnosis that has multiple manifestations, which code should be assigned?

Accepted Answer

The code that most specifically identifies the condition.

Answer

The code with the highest number of characters

Answer

The code that appears first in the index