NHA Medical Billing & Coding (CBCS) — All Questions

Current ICD-10-CM pressure ulcer codes are structured so that a single combination code captures:

• a.only the stage, requiring a separate site code
• b.only the site, requiring a separate stage code
• c.both the anatomical site and the stage of the ulcer✓
• d.the organism responsible for the ulcer

Pressure ulcer codes are combination codes that identify the site and the stage together, so a separate stage or site code is not needed.

The ICD-10-CM Neoplasm Table provides code columns for malignant primary, malignant secondary, and:

• a.acute and chronic phases of the tumor in every billing situation without exception
• b.carcinoma in situ, benign, uncertain behavior, and unspecified behavior✓
• c.initial and subsequent encounters
• d.right and left laterality only

The Neoplasm Table has columns for malignant primary, malignant secondary, carcinoma in situ, benign, uncertain behavior, and unspecified behavior. The coder must determine the behavior before selecting a column.

When a patient is admitted for an HIV-related condition, ICD-10-CM guidelines require the coder to sequence:

• a.the related condition first, then the HIV code
• b.only the HIV code and none of the related conditions in every billing situation without exception
• c.the HIV code first, followed by the codes for the related conditions✓
• d.an asymptomatic HIV status code first

For an HIV-related admission, the HIV code (B20) is sequenced first, then the related conditions. The asymptomatic status code (Z21) is used only when no HIV-related condition is present.

For a patient admitted with sepsis due to a localized infection, ICD-10-CM guidelines generally direct that:

• a.sepsis is coded only if organ failure is present
• b.the localized infection is always sequenced first in every billing situation without exception
• c.the underlying systemic infection code is sequenced first✓
• d.only the localized infection is coded

Code the underlying systemic infection (sepsis) first, then the localized infection if applicable. If severe sepsis is documented, a code from R65.2- and the associated organ dysfunction codes are also assigned.

The distinction in ICD-10-CM between a 'poisoning' and an 'adverse effect' of a drug is that a poisoning involves:

• a.a drug taken improperly, such as a wrong dose or wrong substance✓
• b.any reaction to any medication
• c.only illegal or controlled substances
• d.a drug that was administered by a physician in every billing situation without exception

A poisoning results from improper use, such as overdose or taking the wrong substance. An adverse effect occurs when a correctly prescribed and correctly taken drug causes a reaction. The Table of Drugs and Chemicals guides code selection.

In ICD-10-CM, 'underdosing' refers to:

• a.taking less of a medication than prescribed or instructed✓
• b.a reaction to a correctly taken drug
• c.an intentional poisoning attempt
• d.taking more of a medication than prescribed in every billing situation without exception

Underdosing is taking less than the prescribed or instructed dose. It is never sequenced first; the medical condition is coded first, followed by the underdosing code and an intent code such as noncompliance.

The ICD-10-CM Table of Drugs and Chemicals lists poisoning columns by intent, plus additional columns for:

• a.primary and secondary neoplasms
• b.initial and subsequent encounters
• c.adverse effect and underdosing✓
• d.right and left laterality

The Table of Drugs and Chemicals has columns for poisoning by intent (accidental, self-harm, assault, undetermined) plus adverse effect and underdosing.

When coding multiple burns of different severities at different sites, ICD-10-CM guidelines direct the coder to sequence first the code for the:

• a.burn that is easiest to treat
• b.most recently sustained burn
• c.highest-degree (most severe) burn✓
• d.burn covering the smallest surface area

Sequence the highest-degree burn first. Also assign codes for the total body surface area involved and report each burn by depth, site, and extent.

ICD-10-CM burn codes in categories T31 and T32 classify burns according to:

• a.the phase of healing
• b.the causative agent only in every billing situation without exception regardless of what the medical record documents
• c.the anatomical site only
• d.the total body surface area involved, including the portion that is third-degree✓

T31 and T32 report the extent of burns by total body surface area, often estimated using the rule of nines, and the percentage that is third-degree.

Under current ICD-10-CM guidelines, a causal relationship between hypertension and heart disease such as heart failure is:

• a.never assumed, so unrelated codes are always used
• b.reported together with an external cause code
• c.presumed, so a combination code is assigned unless the record states they are unrelated✓
• d.coded only when the provider writes the word hypertensive in every billing situation without exception

The 'with' guideline presumes a relationship between hypertension and heart disease, so a hypertensive heart disease combination code is assigned along with the heart failure type, unless the provider documents them as unrelated.

For a patient with type 2 diabetes and diabetic chronic kidney disease, ICD-10-CM guidelines direct the coder to:

• a.code the diabetes and the kidney disease as unrelated conditions in every billing situation without exception
• b.code only the chronic kidney disease
• c.wait for the provider to explicitly link the two
• d.assign a combination code linking the diabetes to the kidney manifestation, plus the CKD stage code✓

Diabetes combination codes assume the relationship under the 'with' guideline, so a diabetic chronic kidney disease code is assigned along with the specific CKD stage code, without needing an explicit linkage statement.

A Z code for a routine screening, such as a screening colonoscopy on an asymptomatic patient, is:

• a.always sequenced after a symptom code
• b.never allowed as a first-listed diagnosis in every billing situation without exception
• c.reported only on inpatient claims
• d.assigned as the first-listed diagnosis for the screening encounter✓

Screening Z codes may be first-listed for the encounter. If a condition is discovered during the screening, it may be coded additionally, but the screening remains the reason for the visit.

A personal history code (categories Z85 to Z87) in ICD-10-CM is appropriately used when:

• a.the patient currently has the active condition in every billing situation without exception
• b.the condition is only suspected
• c.a past condition no longer exists but may affect current care or requires monitoring✓
• d.a family member has the condition

Personal history codes indicate a resolved past condition that could influence current care, such as a history of cancer requiring surveillance. Family history codes describe conditions in relatives.

For routine healing care of a traumatic fracture, ICD-10-CM guidelines direct the coder to use:

• a.an aftercare Z code instead of the fracture code
• b.the fracture code with the initial-encounter seventh character in every billing situation without exception
• c.the fracture code with the seventh character for a subsequent encounter, not an aftercare Z code✓
• d.no code at all because the care is routine

For injuries, routine subsequent care uses the injury code with the appropriate seventh character, such as 'D', rather than an aftercare Z code. Aftercare Z codes apply to other situations like surgical aftercare.

When a single ICD-10-CM combination code fully identifies both a condition and its complication, the coder should:

• a.assign whichever set of codes pays more
• b.assign only the combination code✓
• c.assign only the separate individual codes
• d.assign the combination code plus each individual code

Use the combination code alone when it fully describes the condition and its complication. Multiple coding is used only when the combination code lacks the necessary specificity.

The term 'principal diagnosis,' as opposed to 'first-listed diagnosis,' applies specifically to:

• a.external cause of injury reporting
• b.any claim submitted on the CMS-1500 form in every billing situation without exception regardless of what the medical record documents
• c.outpatient physician office coding
• d.inpatient hospital coding, being the condition established after study to be chiefly responsible for admission✓

Principal diagnosis is an inpatient concept: the condition, established after study, chiefly responsible for the admission. Outpatient and physician office coding uses the term first-listed diagnosis.

A present-on-admission (POA) indicator is reported on:

• a.inpatient hospital claims, to show whether a diagnosis was present at admission✓
• b.outpatient laboratory claims
• c.retail prescription drug claims
• d.every professional claim on the CMS-1500 in every billing situation without exception

POA indicators apply to inpatient acute-care hospital diagnoses, distinguishing conditions present at admission from those that developed during the stay. They can affect payment for certain hospital-acquired conditions.

When documentation in the record is ambiguous, conflicting, or incomplete, the coder's most appropriate action is to:

• a.submit a query to the provider for clarification✓
• b.assign an unspecified code without further review
• c.assign the code that yields the highest payment
• d.make an assumption based on clinical experience

Coders must not assume or infer a diagnosis. When documentation is unclear, the correct step is to query the provider, because codes are assigned only from provider documentation.

Abnormal findings on a diagnostic test, such as a lab result, should be coded in the outpatient setting only when:

• a.the test was ordered by a specialist
• b.the value is outside the reference range, regardless of documentation
• c.the provider documents their clinical significance✓
• d.the patient specifically requests it

Abnormal findings are not coded from the result alone. The coder assigns a related diagnosis only when the provider documents its clinical significance, or queries the provider for clarification.

Regarding the timing of sequela (late effect) coding in ICD-10-CM, there is generally:

• a.a rule that sequelae are coded only at the initial encounter
• b.no specific time limit for when a sequela code may be used✓
• c.a requirement that the sequela appear within one year
• d.a strict 90-day limit after the injury

A sequela is the residual effect that remains after the acute phase of an illness or injury has ended. There is no fixed time frame; it may appear soon after or years later.

CPT Category II codes are supplemental tracking codes that:

• a.describe emerging technology on a temporary basis in every billing situation without exception
• b.replace the ICD-10-CM diagnosis codes
• c.are required on every claim and generate payment
• d.are optional, support performance measurement, and carry no relative value for payment✓

Category II codes, ending in the letter F, are optional codes used for performance and quality measurement. They are not assigned relative value units and are not paid.

In the CPT codebook, a solid dot (bullet) placed before a code indicates that the code is:

• a.revised from the prior edition
• b.exempt from modifier 51
• c.an add-on code
• d.new to the current edition✓

A bullet marks a new code. A triangle marks a revised code, a plus sign marks an add-on code, and a circle with a slash marks a modifier-51-exempt code.

In CPT, the plus symbol preceding a code identifies it as an add-on code, which means the code is:

• a.a temporary code for new technology
• b.reported alone as a standalone service in every billing situation without exception
• c.reported in addition to a primary procedure and is exempt from modifier 51✓
• d.used only for anesthesia services

Add-on codes, marked with a plus sign, are always performed in addition to a primary procedure and are exempt from modifier 51 multiple-procedure reductions. They cannot be reported alone.

The CPT symbol of a circle with a slash placed before a code indicates the code is:

• a.new to the current edition
• b.exempt from modifier 51✓
• c.a Category III code
• d.an unlisted procedure

The circle-with-slash symbol identifies modifier-51-exempt codes, which should not have modifier 51 appended even when reported with other procedures.

When no specific CPT code exists for a service performed, the coder should:

• a.use a Category II tracking code instead
• b.report an unlisted procedure code with supporting documentation✓
• c.omit the service from the claim entirely
• d.select the closest available code even if it is inaccurate

Unlisted procedure codes, often ending in 99, are used when no Category I or III code describes the service. A report or description must accompany the claim so the payer can review it manually.

Modifier 50 is appended to a CPT code to indicate that a procedure was:

• a.reduced in scope by the provider in every billing situation without exception
• b.repeated by a different provider
• c.performed bilaterally during the same session✓
• d.the professional component only

Modifier 50 reports a bilateral procedure performed on mirror-image body parts in the same session. Payer reporting conventions for bilateral procedures, such as one line versus two, may vary.

Modifier 52 is used when a service or procedure is:

• a.discontinued after anesthesia because of patient risk in every billing situation without exception
• b.performed by two co-surgeons
• c.partially reduced or eliminated at the provider's discretion✓
• d.increased in complexity beyond the usual

Modifier 52 indicates reduced services, meaning a procedure was partly reduced or eliminated by the provider's choice. Modifier 53 is used for a procedure discontinued because of a threat to the patient.

Modifier 53 is appropriately appended when a procedure is:

• a.electively reduced before it begins
• b.postponed before anesthesia for scheduling reasons in every billing situation without exception
• c.performed with an assistant surgeon
• d.discontinued after it has begun because of a threat to the patient's well-being✓

Modifier 53 identifies a discontinued procedure due to extenuating circumstances or a threat to the patient after the procedure or anesthesia had begun. It is not used for elective cancellations before anesthesia.

Modifier 76 indicates a repeat procedure by the same physician, whereas modifier 77 indicates a repeat procedure by:

• a.the facility rather than a physician
• b.an assistant surgeon
• c.a resident in training
• d.a different physician✓

Modifier 76 identifies a repeat procedure by the same physician; modifier 77 identifies a repeat by a different physician. Both signal that the repeat was intentional, not a duplicate billing error.

Modifier 78 is used for an unplanned return to the operating room for a related procedure during the postoperative period, while modifier 79 is used for a procedure that is:

• a.reduced in scope from the original
• b.unrelated to the original surgery during the postoperative period✓
• c.a staged or planned part of the original procedure in every billing situation without exception
• d.performed on the same day as the original surgery

Modifier 78 covers an unplanned related return to the operating room during the global period; modifier 79 covers an unrelated procedure during the postoperative period; modifier 58 covers a staged or planned procedure.

Modifier 58 identifies a procedure during the postoperative period that was:

• a.unrelated to the first procedure
• b.discontinued before completion
• c.an unplanned return for a complication in every billing situation without exception
• d.planned or staged, more extensive, or therapy following a diagnostic procedure✓

Modifier 58 indicates a staged or planned procedure, a more extensive procedure, or therapy following a diagnostic service, performed during the global period by the same physician.

Modifier 24 is appended to an evaluation and management service to indicate that it was:

• a.the decision-making visit for surgery
• b.provided by a different physician than the surgeon
• c.a significant, separately identifiable service on the same day as a procedure
• d.unrelated to the surgery and provided during the postoperative period✓

Modifier 24 identifies an unrelated E/M service during a global postoperative period by the same physician. Modifier 25 covers a same-day separate E/M, and modifier 57 covers the decision for major surgery.

Modifier 57 is appended to an evaluation and management service that resulted in:

• a.a minor procedure performed on the same day in every billing situation without exception
• b.the decision to perform a major surgery, typically the day of or day before✓
• c.a reduced service
• d.an unrelated postoperative visit

Modifier 57 marks an E/M service that led to the decision for a major surgery, usually the day of or the day before. Modifier 25 is used with minor procedures instead.

Modifier 80 is used to report the services of a(n):

• a.assistant surgeon✓
• b.surgical team of three or more surgeons
• c.second primary surgeon of a different specialty
• d.resident supervised by a teaching physician

Modifier 80 reports assistant surgeon services. Modifier 62 identifies co-surgeons, modifier 66 identifies a surgical team, and modifier 82 is used when a qualified resident is not available.

Modifier 62 is reported when:

• a.a service is reduced from the usual
• b.a procedure is repeated by the same surgeon in every billing situation without exception
• c.one surgeon is aided by an assistant
• d.two surgeons work together as primary surgeons on distinct parts of one procedure✓

Modifier 62 identifies co-surgeons, where two surgeons each perform a distinct part of the same procedure. Each surgeon reports the same procedure code with modifier 62.

Modifier 90 is appended to a laboratory code when:

• a.only the interpretation is billed
• b.a test is repeated on the same day
• c.the test is performed by an outside reference laboratory✓
• d.the specimen is collected at the patient's home in every billing situation without exception

Modifier 90 identifies a reference (outside) laboratory that performed the test billed by the ordering provider. Modifier 91 covers a medically necessary repeat of the same lab test on the same day.

Modifier 91 is correctly used when a clinical diagnostic laboratory test is:

• a.repeated on the same day to obtain subsequent, medically necessary results✓
• b.sent to an outside reference laboratory
• c.repeated because of a testing or equipment error in every billing situation without exception
• d.performed as part of a defined panel

Modifier 91 reports a medically necessary repeat of the same lab test on the same day, such as serial glucose readings. It is not used for re-runs due to specimen or equipment problems.

Modifier 22 indicates that a procedure required:

• a.an unrelated E/M service
• b.substantially greater work than typically required, supported by documentation✓
• c.reduced or eliminated services in every billing situation without exception regardless of what the medical record documents
• d.a bilateral surgical approach

Modifier 22 identifies increased procedural services due to unusual difficulty. Documentation must justify the additional work, which may support higher payment on manual review.

HCPCS Level II codes beginning with the letter 'J' are used primarily to report:

• a.drugs administered by injection or infusion, other than oral✓
• b.orthotic and prosthetic devices
• c.ambulance and transport services in every billing situation without exception
• d.durable medical equipment items

J codes report non-orally administered drugs, such as injectable or infused medications. The units billed must reflect the dosage amount stated in the code description.

When billing a HCPCS 'J' drug code, the number of units reported must reflect:

• a.the number of vials opened during the visit in every billing situation without exception
• b.the total minutes the drug was infused
• c.the dosage in the code description relative to the amount administered✓
• d.the patient's body weight in kilograms

Units are reported based on the code's defined dosage increment compared with the amount given. For example, if a code represents 10 mg and 30 mg is administered, three units are billed. Miscounting units is a common billing error.

The HCPCS Level II modifiers LT and RT are used to identify:

• a.the professional and technical components in every billing situation without exception
• b.assistant surgeon services
• c.a reduced service
• d.the left or right side of the body for a procedure or item✓

LT and RT designate laterality, left or right, for procedures and durable medical equipment. Some payers prefer LT and RT on separate lines rather than modifier 50 for bilateral items.

HCPCS Level II modifiers such as FA and F1 through F9 are used to identify:

• a.specific toes on the foot in every billing situation without exception
• b.the eyelids
• c.specific fingers on which a procedure was performed✓
• d.the coronary arteries

FA and F1 through F9 identify individual fingers; TA and T1 through T9 identify toes; and E1 through E4 identify eyelids. These anatomic modifiers support billing for distinct sites.

The HCPCS modifier GA indicates that:

• a.the service is statutorily excluded from Medicare
• b.a required Advance Beneficiary Notice of Noncoverage is on file✓
• c.the provider expects the service to be paid in full in every billing situation without exception
• d.the service was performed bilaterally

Modifier GA shows that a signed ABN is on file for a service Medicare is expected to deny. Modifier GZ means no ABN was obtained, and GY means the service is statutorily excluded.

For CPT office E/M coding, a patient is considered 'new' when he or she has not received professional services from the physician, or another physician of the same specialty and group, within the past:

• a.three years✓
• b.five years
• c.one year
• d.six months

A new patient is one who has not received a face-to-face professional service from the physician, or a same-specialty physician in the same group, within the prior three years. Otherwise the patient is established.

Under current office E/M guidelines, the level of medical decision making is determined by the number and complexity of problems, the risk of complications, and:

• a.the total charge for the visit
• b.the number of body systems examined
• c.the amount and complexity of data reviewed and analyzed✓
• d.the length of the history of present illness in every billing situation without exception

Medical decision making has three elements: the problems addressed, the data reviewed and analyzed, and the risk. Two of the three drive the level. History and exam no longer determine the level for office visits.

Under current office E/M guidelines, which activity performed by the physician on the date of the encounter may count toward total time?

• a.Travel time to a different facility
• b.Reviewing the patient's outside test results and documenting in the record✓
• c.Time spent caring for a different patient
• d.Time spent by clinical staff rooming the patient in every billing situation without exception

Total time includes the physician's face-to-face and non-face-to-face work on the date of the encounter, such as reviewing records, ordering tests, counseling, and documenting. Staff time and unrelated work do not count.

A CPT consultation code requires a request from another provider, the consultant's opinion, and:

• a.a second surgical opinion only
• b.a referral of the patient to a hospital
• c.a transfer of the patient's care to the consultant in every billing situation without exception
• d.a written report of the findings back to the requesting provider✓

A consultation requires a request, the rendering of an opinion or service, and a written report back to the requesting provider. If the consultant assumes ongoing care, it becomes a transfer of care.

CPT critical care codes are reported based on:

• a.the place of service alone
• b.a flat rate per hospital admission
• c.the total time the physician spends providing critical care✓
• d.the number of organ systems that are failing in every billing situation without exception

Critical care codes are time-based. The first code covers the first 30 to 74 minutes, and an add-on code covers each additional 30 minutes of critical care for a critically ill or injured patient.

CPT preventive medicine service codes are selected based on:

• a.the severity of the presenting complaint in every billing situation without exception
• b.whether the patient is new or established and the patient's age✓
• c.the total counseling time only
• d.the number of chronic problems managed

Preventive medicine codes are chosen by new or established status and the patient's age group. If a significant separate problem is also addressed, a problem-oriented E/M with modifier 25 may be reported.

When coding an excision of a skin lesion in CPT, the size measured for code selection is the:

• a.length of the incision line
• b.size of the specimen after fixation in the lab
• c.diameter of the lesion only, excluding margins in every billing situation without exception
• d.greatest diameter of the lesion plus the narrowest surgical margins✓

The excised diameter equals the lesion's greatest diameter plus the narrowest margin on each side, measured before excision. Whether the lesion is benign or malignant and its site also affect code choice.