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.

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.

In CPT, the choice between a benign and a malignant lesion excision code is based on:

• a.the age of the patient
• b.the nature of the lesion, typically confirmed by the pathology report✓
• c.the surgeon's contracted fee schedule in every billing situation without exception
• d.the size of the incision only

Selecting a benign or malignant excision code depends on the nature of the lesion, best confirmed by pathology. Coders may need to wait for the pathology report before finalizing the code.

When multiple wounds of the same complexity and same anatomical group are repaired, CPT directs the coder to:

• a.add the lengths together and report a single code for the summed length✓
• b.use an unlisted repair procedure code
• c.report a separate code for each individual wound in every billing situation without exception
• d.report only the single longest wound

Repairs of the same classification and anatomic grouping are summed by length and reported with one code. Repairs of different classifications or different anatomic groups are reported separately.

A wound repair that requires layered closure of deeper subcutaneous tissue and superficial fascia is classified in CPT as:

• a.complex repair
• b.an unlisted repair
• c.simple repair
• d.intermediate repair✓

Simple repair is a superficial, one-layer closure. Intermediate repair involves layered closure of deeper tissue. Complex repair goes beyond layered closure, such as scar revision or extensive undermining.

The CPT global obstetric package for routine maternity care generally includes antepartum care, delivery, and:

• a.all newborn care after delivery
• b.postpartum care✓
• c.any unrelated surgery during pregnancy
• d.infertility treatment before conception

The global obstetric package bundles routine antepartum visits, delivery, and postpartum care into one code. Complications or unrelated care are reported separately.

A CPT code identified as a 'separate procedure' should be reported:

• a.with every related major procedure it accompanies in every billing situation without exception
• b.only when performed independently, not as an integral part of a larger procedure✓
• c.as an add-on code to a primary procedure
• d.only on inpatient hospital claims

A separate procedure code is bundled when performed as part of a larger service. It is reported alone only when performed independently, at a different site, or in a different session, where modifier 59 may apply.

When a diagnostic endoscopy leads to a surgical endoscopy in the same session, the coder generally reports:

• a.only the diagnostic endoscopy
• b.an unlisted endoscopy code
• c.only the surgical endoscopy, since the diagnostic scope is included✓
• d.both the diagnostic and the surgical endoscopy separately in every billing situation without exception

A diagnostic endoscopy is included in a surgical endoscopy performed at the same site and session, so only the therapeutic procedure is reported. Endoscopy families have specific bundling rules.

Anesthesia payment under CPT is commonly calculated using base units, time units, and:

• a.any applicable modifying units✓
• b.the facility's revenue code
• c.the surgeon's assistant fee
• d.the number of diagnoses reported

Anesthesia payment uses the formula of base units plus time units plus modifying units, multiplied by a conversion factor. Physical status modifiers and qualifying circumstances can add modifying units.

The anesthesia physical status modifier 'P3' describes a patient with:

• a.brain death, with organs removed for donation
• b.a mild systemic disease
• c.no systemic disease, a normal healthy patient
• d.a severe systemic disease✓

Physical status modifiers range from P1, a normal healthy patient, to P6, a declared brain-dead donor. P3 identifies a patient with a severe systemic disease.

When a child receives a vaccine, CPT coding generally requires reporting:

• a.only the administration code
• b.a single combination code for both in every billing situation without exception
• c.a code for the vaccine product and a separate code for its administration✓
• d.only the vaccine product code

A complete immunization service is billed with two components: the vaccine or toxoid product code and the immunization administration code, which may include counseling for younger patients.

Modifier 33 is appended to identify a service as:

• a.an assistant surgeon service
• b.a repeat clinical laboratory test in every billing situation without exception regardless of what the medical record documents
• c.a preventive service, which may waive patient cost-sharing under applicable rules✓
• d.a reduced service

Modifier 33 flags a preventive service, such as one recommended by the U.S. Preventive Services Task Force, so that patient cost-sharing may be waived under the Affordable Care Act.

In medical terminology, the suffix '-ectomy' means:

• a.surgical removal or excision✓
• b.creation of a new opening
• c.surgical repair of a structure
• d.surgical incision into a structure

The suffix -ectomy means excision or removal, as in appendectomy. In contrast, -otomy means incision, -ostomy means creating an opening, and -plasty means surgical repair.

The suffix '-ostomy' differs from '-otomy' in that '-ostomy' refers to:

• a.removing an organ or structure
• b.cutting into a structure without leaving an opening
• c.creating a new, often permanent, opening✓
• d.suturing a structure closed

The suffix -ostomy means surgically creating an opening or stoma, such as a colostomy. The suffix -otomy means a simple incision, such as a laparotomy, and -ectomy means removal.

The suffix '-itis' in a diagnostic term indicates:

• a.surgical repair
• b.inflammation✓
• c.the study of a subject
• d.an abnormal condition

The suffix -itis means inflammation, as in appendicitis or arthritis. In contrast, -osis means an abnormal condition, -ology means the study of, and -pathy means disease.

The prefixes 'hyper-' and 'hypo-' respectively indicate:

• a.within and outside in every billing situation without exception
• b.above or excessive, and below or deficient✓
• c.fast and slow
• d.before and after

Hyper- means excessive or above, as in hyperglycemia, and hypo- means deficient or below, as in hypoglycemia. Tachy- and brady- mean fast and slow, and intra- and extra- mean within and outside.

In surgical terminology, the suffix '-rrhaphy' means suturing, while '-pexy' means:

• a.recording or producing an image
• b.visual examination of a cavity
• c.surgical fixation or suspension of a structure✓
• d.surgical crushing of a structure in every billing situation without exception

The suffix -rrhaphy means suture or repair, as in herniorrhaphy, and -pexy means surgical fixation, as in nephropexy. The suffix -tripsy means crushing, and -scopy means visual examination.

In medical terminology, a combining vowel, usually the letter 'o', is generally used to:

• a.replace the suffix of a term
• b.connect a root to a consonant-starting suffix, or to connect two roots✓
• c.always separate a prefix from a root in every billing situation without exception
• d.indicate the plural form of a word

A combining vowel links a root to a suffix that begins with a consonant, or joins two roots, as in gastroenterology. It is usually dropped before a suffix that begins with a vowel, as in gastritis.

In anatomy, the term 'distal' describes a location that is:

• a.toward the front of the body
• b.toward the head of the body
• c.nearer to the midline of the body in every billing situation without exception
• d.farther from the point of attachment or origin of a structure✓

Distal means farther from the trunk or origin; the fingers are distal to the wrist. Proximal means nearer. Medial and lateral refer to the midline, and superior and inferior mean above and below.

The anatomical plane that divides the body into anterior and posterior portions is the:

• a.coronal (frontal) plane✓
• b.sagittal plane
• c.midsagittal plane
• d.transverse plane

The coronal or frontal plane divides the body into front and back. The sagittal plane divides it into left and right, and the transverse plane divides it into upper and lower portions.

The thoracic cavity primarily contains the:

• a.stomach and intestines
• b.brain and spinal cord
• c.urinary bladder and rectum
• d.heart and lungs✓

The thoracic cavity houses the heart, lungs, and major vessels. The abdominal cavity holds digestive organs, the pelvic cavity holds the bladder and reproductive organs, and the cranial and spinal cavities hold the central nervous system.

When abstracting a procedure code from an operative report, the coder should rely primarily on the:

• a.preoperative diagnosis listed at the top in every billing situation without exception
• b.anesthesia record alone
• c.body of the operative report describing what was actually performed✓
• d.scheduling note created before the case

The detailed body of the operative report, describing the findings and steps actually performed, governs code assignment, because the planned procedure may differ from what was done. The postoperative diagnosis is usually more accurate than the preoperative one.

A Medically Unlikely Edit (MUE) differs from an NCCI procedure-to-procedure edit in that an MUE limits:

• a.the maximum units of a single code reportable for one patient in one day✓
• b.the diagnosis codes that are allowed
• c.which two codes may be billed together in every billing situation without exception
• d.the timely filing period for the claim

MUEs cap the units of service for a single code per patient per day, while procedure-to-procedure edits identify code pairs that should not be reported together. Both are components of the National Correct Coding Initiative.

ICD-10-PCS procedure codes, as distinct from CPT codes, are used to report procedures in the:

• a.ambulance transport setting
• b.inpatient hospital setting✓
• c.physician office setting
• d.retail pharmacy setting

ICD-10-PCS codes report procedures in the inpatient hospital setting, while CPT and HCPCS codes report physician and outpatient procedures. Each system has its own structure and guidelines.