Coding 1 Review

What does HIPAA stand for?

• Health Information Portability and Privacy Act

• Health Information Privacy and Accountability Act

• Health Insurance Portability and Accountability Act

• Health Insurance Privacy and Accountability Act

Which of the following is a term or series of terms that appear in parentheses following a main term or subterm?

• Cause

• Site

• Clinical Type

• Nonessential Modifier

What are PCS codes used for?

• Only outpatient procedures

• Only for Inpatient encounters

• For Inpatient and Outpatient encounters

• For Provider billing

How many characters are in a PCS code

• 3-7

• 7

• 5

• 2-5

An external approach is used when procedures:

• Involve cutting through the skin or mucous membrane

• Involve entry by puncture or minor incision of instrumentation through the skin or mucous membrane

• Are performed directly on the skin or mucous membrane

• Involve entry of instrumentation through a natural or artificial external opening

Which of the following is the UHDDS definition for principal diagnosis?

• A diagnosis affecting the current hospital stay

• The condition established after study to be chiefly responsible for occasioning the admission

• A condition that coexists at the time of admission

• A condition that affects the treatment or length of stay.

When reporting additional diagnoses, a coder should report diagnoses that affect patient care and may include all of the following except ___________.

• Clinical evaluation

• Diagnostic procedures

• Extended length of hospital stay

• A resolved condition

A significant procedure has all of the following except ___________.

• Carries an anesthetic risk

• Carries a procedural risk

• Requires specialized instrumentation

• Requires specialized training

According to coding guidelines for chapter 21 of ICD-10-CM, the body mass index (BMI) codes should be assigned in which of the following scenarios?

• When the person is pregnant and the BMI value is documented in the record

• Whenever the BMI value is documented in an inpatient or outpatient record and meets the definition of a reportable diagnosis

• When the BMI value is documented with the associated diagnosis such as overweight or obesity that meets the definition of a reportable diagnosis

• When the BMI is documented by the physician health care provider

A personal history of a condition is intended to mean what about the patient?

• The patient’s medical condition is no longer present

• The patient is no longer receiving treatment for the condition

• The patient is no longer taking medication for the condition

• All are correct