NHA Medical Billing & Coding (CBCS) — All Questions

In ICD-10-CM, what does the abbreviation NOS in the Alphabetic Index or Tabular List indicate?

• a.The documentation is unspecified, so an 'unspecified' code is assigned✓
• b.The code requires an additional character to be complete
• c.Two separate codes must be combined into one
• d.The condition should never be coded as a primary diagnosis

NOS stands for 'not otherwise specified' and is equivalent to 'unspecified.' It is used when the medical record lacks the detail needed to assign a more specific code. Coders should query the provider when greater specificity is clinically documented but not captured.

An ICD-10-CM code shown with a dash (for example, S52.5-) in a coding reference most directly signals that:

• a.The code is exempt from the diagnosis present-on-admission indicator
• b.The code may only be used for external causes
• c.The code has been deleted from the current code set
• d.Additional characters are required to reach a valid, complete code✓

A trailing dash is a placeholder convention indicating that the code is incomplete and needs one or more additional characters. Submitting a truncated code that lacks required characters will cause the claim to be rejected. The coder must consult the Tabular List to assign all required characters, including any seventh character.

The ICD-10-CM convention 'code first' instructs the coder to:

• a.Assign the code that generates the highest reimbursement first
• b.Report only the manifestation and omit the underlying condition
• c.Sequence the underlying etiology or cause before the manifestation code✓
• d.Always list the code with the highest numeric value first

'Code first' is a sequencing instruction telling the coder to list the underlying condition or etiology ahead of the associated manifestation. Manifestation codes cannot stand alone as a first-listed or principal diagnosis. This mirrors the etiology/manifestation convention found throughout the code set.

In the ICD-10-CM Tabular List, the note 'Excludes1' means:

• a.The excluded code is an acceptable synonym for the listed code
• b.The two conditions may be coded together when both are documented
• c.The two conditions are mutually exclusive and should not be coded together✓
• d.An additional code should be assigned to fully describe the condition

An Excludes1 note is a 'not coded here' instruction indicating the two conditions cannot occur together and should never be reported on the same encounter for the same condition. In contrast, an Excludes2 note means the excluded condition is separate and may be coded additionally if the patient has both. Confusing the two notes is a common source of coding errors.

Which seventh character in an ICD-10-CM injury code identifies a subsequent (follow-up) encounter during the healing phase?

• a.S, for sequela
• b.D, for subsequent encounter✓
• c.A, for initial encounter
• d.X, for a placeholder

For most injury and external-cause codes, the seventh character 'D' denotes a subsequent encounter, when the patient is receiving routine care during the healing or recovery phase. 'A' is the initial encounter for active treatment, and 'S' identifies a sequela, or late effect. The letter X can serve as a placeholder to fill empty character positions so the seventh character stays in the correct slot.

The main term used to locate a diagnosis in the ICD-10-CM Alphabetic Index is generally:

• a.The condition, disease, or reason for the encounter✓
• b.The type of insurance the patient carries
• c.The name of the treating provider's specialty
• d.The anatomical site of the condition

Diagnoses are indexed by the condition, disease, injury, or symptom (the main term), not by the body site. Anatomical site and other details usually appear as subterms indented beneath the main term. Coders locate the term in the Index, then verify the code in the Tabular List before final assignment.

The Current Procedural Terminology (CPT) code set is divided into three categories. Category I codes primarily describe:

• a.Performance-measurement and quality tracking data
• b.Durable medical equipment and supplies
• c.Widely performed procedures and services with FDA-approved technology✓
• d.Emerging or experimental technologies and services

Category I CPT codes are five-digit numeric codes representing established procedures and services that are consistent with contemporary medical practice. Category II codes are supplemental tracking codes for performance measurement, and Category III codes are temporary codes for emerging technology. Only Category I codes have relative value units assigned for standard payment.

CPT Category III codes are best described as:

• a.Temporary codes for emerging technologies, services, and procedures✓
• b.Codes used exclusively for anesthesia services
• c.Quality-measurement codes that carry no procedure meaning
• d.Permanent codes for well-established surgical procedures

Category III codes are temporary alphanumeric codes (four digits followed by the letter T) used to track new and emerging technologies. Using them allows data collection on utilization and outcomes before a service may be considered for Category I status. They are archived or converted after a set period if not adopted.

HCPCS Level II codes are chiefly used to report:

• a.Products, supplies, and services not covered by CPT, such as durable medical equipment and certain drugs✓
• b.Inpatient hospital room-and-board charges
• c.International diagnosis classifications
• d.Physician evaluation and management visits

HCPCS Level II is a national code set (alphanumeric, one letter followed by four digits) maintained by CMS to report items such as durable medical equipment, prosthetics, orthotics, supplies, ambulance services, and drugs administered other than by mouth. These are items generally not found in CPT (HCPCS Level I). Payers rely on Level II codes to adjudicate supply and drug claims.

A modifier appended to a CPT code is used to:

• a.Indicate that a service was altered by a specific circumstance without changing the code's core meaning✓
• b.Signal that the claim is being submitted late
• c.Change the fundamental definition of the procedure code
• d.Replace the diagnosis code on the claim

Modifiers are two-character codes that provide additional information about a service, such as that a procedure was bilateral, was reduced, or was performed by more than one provider, without redefining the procedure itself. Correct modifier use supports clean claims and appropriate reimbursement. Omitting a needed modifier is a frequent cause of denials.

Modifier 26 is appended to a diagnostic service to indicate that only the:

• a.Service was performed by a resident under supervision
• b.Technical component (equipment and supplies) is being billed
• c.Professional component (the physician's interpretation) is being billed✓
• d.Global service including both components is being billed

Many diagnostic tests, such as radiology, have a professional component (the provider's interpretation and report) and a technical component (the equipment, supplies, and technician). Modifier 26 reports the professional component alone. Modifier TC reports the technical component, and a code billed without either modifier represents the global (combined) service.

Modifier 25 is most appropriately used to report:

• a.A bilateral procedure performed on paired organs
• b.A repeat laboratory test on the same day
• c.A significant, separately identifiable E/M service by the same provider on the same day as another procedure✓
• d.A staged or planned return to the operating room

Modifier 25 tells the payer that on the day a minor procedure was performed, the provider also delivered a distinct, medically necessary evaluation and management service beyond the usual pre- and post-procedure work. Documentation must clearly support the separate E/M service. Misuse of modifier 25 is a common audit target.

Three key components historically used to determine the level of an evaluation and management (E/M) service are:

• a.History, examination, and medical decision making✓
• b.Payer, plan type, and deductible status
• c.Diagnosis, procedure, and place of service
• d.Modifier, units, and charge amount

Traditional E/M level selection was based on the extent of the history, the examination, and the complexity of medical decision making. Contemporary office-visit guidelines allow the level to be chosen by medical decision making or by total time on the date of service. Accurate documentation of these elements supports the code selected.

When selecting an office E/M visit level by time under current guidelines, the coder should count:

• a.Only the minutes spent face-to-face performing the exam
• b.The average time all patients spend in the practice that day
• c.Only the time the patient spent in the waiting room
• d.The total qualifying provider time spent on the date of the encounter, including certain non-face-to-face work✓

Current office and outpatient E/M guidelines permit level selection based on the provider's total time on the date of the encounter, which can include reviewing records, ordering tests, documenting, and coordinating care, not just face-to-face minutes. The provider must document the total time. Alternatively, the level may be chosen by medical decision making.

In coding, 'medical necessity' generally means that a service is:

• a.The most expensive option available to the provider
• b.Requested by the patient regardless of clinical indication
• c.Reasonable and necessary for the diagnosis or treatment of the patient's condition✓
• d.Always covered by every insurance plan

Medical necessity is the standard that a service must be appropriate and needed to evaluate or treat the patient's documented condition to qualify for payment. The diagnosis code must support the procedure code billed. Services deemed not medically necessary are commonly denied even when correctly coded.

The primary or first-listed diagnosis on an outpatient claim should represent:

• a.The condition that is easiest to code
• b.Any chronic condition the patient has ever had
• c.The diagnosis with the highest reimbursement
• d.The main condition, chiefly responsible for the services provided during the encounter✓

For outpatient encounters, the first-listed diagnosis is the reason chiefly responsible for the services rendered that day. Coexisting conditions that affect treatment may be reported as additional diagnoses. Correct sequencing supports both medical necessity and accurate reimbursement.

When a definitive diagnosis has not been established at the end of an outpatient encounter, ICD-10-CM guidelines direct the coder to report:

• a.The most serious disease that could explain the symptoms
• b.No diagnosis code at all
• c.A probable or 'rule-out' diagnosis as if confirmed
• d.The documented signs, symptoms, or reason for the encounter✓

For outpatient and physician office coding, conditions described as 'probable,' 'suspected,' or 'rule out' are not coded as confirmed. Instead, the coder reports the signs, symptoms, or the reason for the visit to the highest known level of certainty. This differs from inpatient rules, where uncertain diagnoses may sometimes be coded.

The instructional note 'use additional code' in ICD-10-CM tells the coder to:

• a.Delete the primary code and use only the additional one
• b.Never assign more than one code for the encounter
• c.Report a secondary code to fully describe the condition when documentation supports it✓
• d.Assign a modifier instead of a second code

'Use additional code' is a convention prompting the coder to add a secondary code that gives a more complete picture, such as an infectious organism or an associated manifestation, when the record supports it. It works together with 'code first' notes to enforce proper sequencing. Ignoring these notes can lead to incomplete claims.

In CPT, an add-on code is one that:

• a.Is always reported without any other code
• b.Describes an additional service performed with a primary procedure and cannot be reported alone✓
• c.Replaces the primary procedure code entirely
• d.Can only be used for laboratory panels

Add-on codes represent services that are always performed in addition to a primary procedure and are typically identified with a plus symbol in CPT. They are exempt from certain multiple-procedure payment reductions and must be reported alongside their primary code. Reporting an add-on code alone will cause a denial.

The 'global surgical package' concept in CPT means that the payment for a surgery generally includes:

• a.Nothing beyond the operating room time
• b.Only the incision itself
• c.The surgeon's fee plus all unrelated future care for a year
• d.The operation plus related preoperative and normal postoperative care for a defined period✓

A surgical package bundles the procedure with typical preoperative evaluation and routine postoperative follow-up during a defined global period. Services within that period that are routine follow-up are not billed separately. Care unrelated to the surgery, or a return to the operating room, may be reported with appropriate modifiers.

Which statement about the ICD-10-CM external cause codes (the V, W, X, and Y codes) is correct?

• a.They may be used as a first-listed or principal diagnosis
• b.They provide supplemental detail about how an injury occurred and are never sequenced first✓
• c.They replace the injury code entirely
• d.They are only used for laboratory results

External cause codes describe the mechanism, intent, place, and activity related to an injury or condition, adding useful public-health detail. They are always secondary and cannot serve as the principal or first-listed diagnosis. Their use is generally voluntary unless mandated by a state or payer.

A 'combination code' in ICD-10-CM is a single code that:

• a.Combines a CPT and an ICD-10-CM code
• b.Represents a bundled surgical package
• c.Classifies two diagnoses, or a diagnosis with an associated manifestation or complication, in one code✓
• d.Merges two unrelated encounters

A combination code captures either two diagnoses, or a diagnosis together with an associated secondary process or complication, in a single code. When a combination code fully describes the condition, only that code is assigned. Assigning separate codes instead would result in unnecessary and potentially incorrect reporting.

In CPT surgical coding, modifier 59 is used to identify a:

• a.Bilateral procedure
• b.Distinct procedural service that is separate from other services performed the same day✓
• c.Professional component only
• d.Reduced service

Modifier 59 indicates that a procedure was distinct or independent from other non-E/M services performed on the same day, such as a different session, site, or organ system. It is used to bypass certain edits when services are truly separate. Because it is frequently misused, more specific X-modifiers were introduced and documentation must support the distinct service.

Which of the following best describes the correct order of coding steps?

• a.Assign the code from the Tabular List, then skip the Index
• b.Read only the Index and never consult the Tabular List
• c.Choose the code with the highest payment, then confirm with the payer
• d.Locate the main term in the Alphabetic Index, then verify the code in the Tabular List✓

Proper coding always begins in the Alphabetic Index to locate the main term and any subterms, followed by verification in the Tabular List where all conventions, notes, and character requirements are checked. Coding directly from the Index alone risks missing required characters or instructional notes. This two-step process helps ensure accurate, complete code assignment.

The 'Z codes' in ICD-10-CM are primarily used to report:

• a.Poisonings and toxic effects
• b.External causes of morbidity
• c.Only fatal conditions
• d.Factors influencing health status and contact with health services, such as screenings or aftercare✓

Z codes describe reasons for encounters other than a current illness or injury, such as routine examinations, immunizations, screenings, aftercare, and personal or family history. Some Z codes may be first-listed while others are only secondary. They help explain the medical necessity of preventive and follow-up visits.

When laterality applies to an ICD-10-CM code, the coder must specify:

• a.The date of the injury
• b.Whether the condition affects the right, left, or is bilateral✓
• c.The severity of the pain only
• d.The provider's specialty

Many ICD-10-CM codes require documentation of laterality, identifying the right side, left side, or bilateral involvement of a paired body part. When the record does not state the side, an 'unspecified' code may be the only option, but this reduces specificity. Coders should query the provider when laterality is clinically relevant but missing.

In CPT, the '-51' modifier is generally appended to indicate:

• a.A repeat clinical laboratory test
• b.A telehealth service
• c.Multiple procedures performed at the same session by the same provider✓
• d.That the patient is deceased

Modifier 51 signals that more than one procedure was performed during the same encounter, which may trigger multiple-procedure payment reductions on the lesser services. It is not appended to add-on codes or to codes designated as modifier-51 exempt. Some payers apply the reduction automatically rather than requiring the modifier.

Upcoding, which is prohibited, refers to:

• a.Reporting a higher-level or more complex service than was actually documented or performed✓
• b.Reporting a lower-level service than was documented
• c.Using the correct modifier on a claim
• d.Bundling two codes into one appropriately

Upcoding is the improper practice of assigning a code that reflects a more severe diagnosis or more expensive service than the documentation supports, in order to obtain higher payment. It is considered fraudulent and can trigger penalties. Coders must assign codes strictly according to the medical record.

Unbundling in coding refers to:

• a.Billing separately for services that should be reported together under a single comprehensive code✓
• b.Assigning the least specific diagnosis available
• c.Reporting only the primary code of a package
• d.Combining several services into one comprehensive code correctly

Unbundling occurs when component parts of a single comprehensive procedure are reported as separate codes to increase reimbursement. National Correct Coding Initiative edits are designed to detect and prevent this. When done to gain higher payment, unbundling is considered abusive or fraudulent billing.

The National Correct Coding Initiative (NCCI) edits are used primarily to:

• a.Prevent improper payment when incorrect code combinations are reported✓
• b.Set the fee schedule amounts for each code
• c.Determine patient deductibles
• d.Assign diagnosis codes automatically

NCCI edits, maintained by CMS, identify pairs of codes that generally should not be billed together for the same patient on the same day, as well as units-of-service limits. They help promote correct coding and prevent improper payments. A modifier may sometimes override an edit when documentation supports a distinct service.

Which resource lists CPT modifiers and their definitions and is essential for accurate procedural coding?

• a.The CMS-1500 claim form instructions only
• b.The patient's insurance card
• c.The CPT codebook, including its appendices✓
• d.The remittance advice

The CPT codebook contains the modifiers along with guidelines and appendices that define their proper use. Coders rely on these official descriptions to append modifiers accurately. Using an outdated or incomplete reference can lead to incorrect modifier application and denials.

The ICD-10-CM Official Guidelines for Coding and Reporting are best described as:

• a.Authoritative rules that accompany the code set and must be followed for accurate code assignment✓
• b.A list of covered services by insurance plan
• c.The fee schedule for each diagnosis
• d.Optional suggestions that payers may ignore

The Official Guidelines are a set of rules developed to accompany and complement the ICD-10-CM conventions and instructions, and adherence to them is required under HIPAA. They govern selection and sequencing of codes in various settings. Coders must apply both the conventions in the code set and these guidelines together.

In the ICD-10-CM Tabular List, an Excludes2 note indicates that:

• a.the excluded condition is separate, so both codes may be reported together when the patient has both✓
• b.the two conditions can never occur in the same patient at any time in every billing situation without exception
• c.the excluded code must always be sequenced first
• d.the code has been deleted and replaced by the excluded code

An Excludes2 note means 'not included here'; the excluded condition is a distinct problem, so if the patient has both, both may be coded. This contrasts with Excludes1, where the two conditions are mutually exclusive.

For an injury coded in ICD-10-CM, the seventh character 'A' is assigned when the patient is:

• a.being seen for routine care during the healing phase
• b.treated for a late effect of the injury
• c.receiving active treatment for the injury✓
• d.returning years later for an unrelated condition

The seventh character 'A' (initial encounter) applies while the patient is receiving active treatment, such as surgery, emergency care, or evaluation by a new provider. 'D' covers routine healing care and 'S' identifies a sequela.

When coding the residual effect of a previous injury, such as a scar contracture remaining after a healed burn, the seventh character 'S' (sequela) requires the coder to:

• a.report only the acute injury code with the seventh character A
• b.list the specific residual condition first, then the injury code with the seventh character S✓
• c.assign the seventh character D because healing is complete
• d.report only the injury code with S and never the residual condition in every billing situation without exception

For a sequela, code the nature of the residual condition first, followed by the injury code with the seventh character 'S'. There is no time limit for using a sequela code.

The placeholder character 'X' is used in certain ICD-10-CM codes to:

• a.mark a code that should never be billed
• b.indicate that the code is unspecified
• c.fill an empty character position so a required seventh character stays in the correct place✓
• d.show that the code is for external causes only in every billing situation without exception regardless of what the medical record documents

The letter X is a placeholder that fills empty positions (common in poisoning codes) so a mandatory seventh character sits in the seventh position. It must never be omitted when required.

An ICD-10-CM code title that includes the phrase 'in diseases classified elsewhere' signals that the code:

• a.requires a seventh character for laterality
• b.is a manifestation code that must be listed after the underlying condition✓
• c.may be reported as the first-listed diagnosis in every billing situation without exception
• d.is used only for external causes of injury

Codes titled 'in diseases classified elsewhere' are manifestation codes that can never be sequenced first; the underlying etiology is coded first, following the etiology/manifestation convention.

In the ICD-10-CM Alphabetic Index, when the term 'with' appears indented under a main term, the linked conditions are interpreted as:

• a.reportable only with an external cause code
• b.assumed to be related unless the documentation states otherwise✓
• c.unrelated and requiring separate encounters
• d.linked only if the provider explicitly documents a cause in every billing situation without exception

Under the 'with' guideline, conditions listed together are presumed to be related, so a combination code is assigned without the provider explicitly linking them, unless the record indicates the conditions are unrelated.

In ICD-10-CM code titles, the word 'and' should be interpreted to mean:

• a.the two conditions are mutually exclusive
• b.either condition but never both together
• c.and/or✓
• d.both conditions must always be present

In ICD-10-CM titles, 'and' means 'and/or'. A code describing, for example, 'tendon and muscle' applies whether one or both structures are involved.

In the ICD-10-CM Alphabetic Index, a 'see' cross-reference instruction directs the coder to:

• a.look under the referenced term because the entry cannot be coded from its current location✓
• b.assign the current code without further review in every billing situation without exception
• c.add a seventh character automatically
• d.report an unspecified code

'See' is a mandatory instruction to go to the referenced main term to locate the correct code. 'See also' is a suggestion to check another term when the current entry does not fully describe the condition.

When a condition is documented without further specification, the code listed next to the main term in the ICD-10-CM Alphabetic Index (the default code) represents:

• a.the most severe form of the disease
• b.the condition most commonly associated with that diagnosis, or its unspecified form✓
• c.a code that always requires a seventh character in every billing situation without exception
• d.the code that yields the highest reimbursement

The default code, printed beside the main term in the Index, is assigned when the documentation lacks detail. It reflects the most common form of the condition or its unspecified variant.

In ICD-10-CM, a code described as 'other specified' (often ending in .8) is assigned when:

• a.the record names a specific condition for which no distinct code exists✓
• b.the documentation gives no detail about the condition in every billing situation without exception
• c.the provider has not yet been asked to clarify
• d.two separate conditions must be combined

'Other specified' means the record identifies a specific condition, but the classification has no unique code for it. 'Unspecified' (often .9) is used when the record lacks the detail to be more specific.

Terms enclosed in parentheses following a main term in the ICD-10-CM Index are nonessential modifiers, which means they:

• a.do not affect code assignment whether or not they appear in the diagnosis✓
• b.change the code to an unspecified one
• c.always require the coder to assign an additional code
• d.must be documented for the code to be considered valid in every billing situation without exception

Nonessential modifiers appear in parentheses and are supplementary; their presence or absence does not change the code selected. Essential modifiers are indented subterms that do affect code selection.

In the ICD-10-CM Tabular List, brackets are used to enclose:

• a.the required seventh character options in every billing situation without exception
• b.codes that must be sequenced first
• c.synonyms, alternative wording, or explanatory phrases✓
• d.external cause codes only

In the Tabular List, brackets enclose synonyms and explanatory phrases. In the Alphabetic Index, brackets identify manifestation codes that must be used with an underlying etiology code.

A 'code also' note in ICD-10-CM instructs the coder to:

• a.always sequence the second code first in every billing situation without exception regardless of what the medical record documents
• b.use only one code for the condition
• c.omit the manifestation code entirely
• d.report two codes to fully describe the condition, without dictating their sequence✓

'Code also' signals that two codes may be needed to describe a condition, but it does not establish sequencing. The order depends on the circumstances of the encounter, unlike 'code first' or 'use additional code' notes.

When a condition is documented as both acute and chronic and the Alphabetic Index lists separate subentries at the same indentation level, the coder should:

• a.assign only the acute code
• b.assign both codes and sequence the acute (or subacute) code first✓
• c.assign only the chronic code
• d.combine them into a single unspecified code in every billing situation without exception

When separate acute and chronic subentries exist at the same level, both are coded, and the acute or subacute condition is sequenced first.

Signs and symptoms that are integral to a confirmed diagnosis in ICD-10-CM should generally:

• a.always be listed as the first diagnosis
• b.be coded in addition to the confirmed diagnosis
• c.replace the definitive diagnosis on the claim
• d.not be coded separately✓

Symptoms routinely associated with a confirmed disease process are not coded separately. Symptoms that are not integral to the condition may be reported as additional codes.

When a condition is documented as 'impending' or 'threatened' but did not actually occur, ICD-10-CM guidelines direct the coder to:

• a.assign a sequela seventh character
• b.always code the condition as though it had occurred in every billing situation without exception regardless of what the medical record documents
• c.check the Index subterms and, if none exists, code the underlying condition rather than the impending one✓
• d.never assign any code for the encounter

Reference the subterms 'impending' and 'threatened' in the Index. If a subentry exists, code it as such; if not, code the existing underlying condition and not the event that was only impending.

If a record does not identify which side of a paired organ is affected but the ICD-10-CM code requires laterality, the coder should generally:

• a.assign the 'unspecified side' code and query the provider when the side is clinically relevant✓
• b.assign the right-side code as a default in every billing situation without exception regardless of what the medical record documents
• c.assign a bilateral code to be safe
• d.omit the diagnosis from the claim

The unspecified-side code is used only when the side truly is not documented. Because this reduces specificity, best practice is to query the provider when laterality is clinically important.

ICD-10-CM codes for body mass index (BMI) may be reported:

• a.in place of the underlying diagnosis
• b.based on the patient's self-report alone
• c.as a first-listed diagnosis for any encounter in every billing situation without exception
• d.only as secondary codes, and only when an associated reportable condition is documented✓

BMI codes are always secondary and require an associated diagnosis such as obesity. BMI may be documented by a non-physician clinician, but the associated condition must be documented by the provider.